PHYSICAL THERAPY PRACTICE the Magazine of the Academy of Orthopaedic Physical Therapy, APTA

2019 / volume 31 / number 1 ORTHOPAEDIC PHYSICAL THERAPY PRACTICE The magazine of the Academy of Orthopaedic Physical Therapy, APTA

FEATURE: Effect of Eccentric Exercises at the Knee with Hip Muscle Strengthening to Treat Patellar Tendinopathy in Active Duty Military Personnel

6938_OP_Jan.indd 501 12/17/18 12:55 PM 6938_OP_Jan.indd 502 12/17/18 12:55 PM ORTHOPAEDIC PHYSICAL THERAPY PRACTICE The magazine of the Academy of Orthopaedic Physical Therapy, APTA

In this issue Regular features

8  Effect of ccentricE Exercises at the Knee with Hip Muscle Strengthening to 3  President's Corner Treat Patellar Tendinopathy in Active Duty Military Personnel: A Randomized Pilot 5  Editor’s Note Kerry MacDonald, Johnathan Day, Carol Dionne 6  New Year, New Editor

18  Manual Therapy and Exercise in Treatment of a Patient with 39  Wooden Book Reviews Cervical Radiculopathy Robert Boyles, Andrew Didricksen, Justin Higa, Daniel Kobayashi 40  Occupational Health SIG Newsletter

24  Manual Therapy Application in the Management of Baastrup’s Disease: 42  Performing Arts SIG Newsletter A Case Report Douglas Steele, Mark Kosier 49  Foot & Ankle SIG Newsletter 50  Pain SIG Newsletter 30  Clinical Application: Physical Examination Procedure to Assess Hip Joint Synovitis/Effusion 54  Imaging SIG Newsletter Damien Howell 55  Orthopaedic Residency/Fellowship 36  Rehabilitation Outcomes Following Primary vs Secondary Repair of SIG Newsletter Ruptured Tibialis Anterior Tendon: A Report of Two Cases Susan Kelvasa, Prarthana Gururaj 57  Animal Rehabilitation SIG Newsletter

60  Index to Advertisers

OPTP Mission Publication Staff Managing Editor & Advertising Editor To serve as an advocate and Sharon L. Klinski Christopher Hughes, PT, PhD, OCS resource for the practice of Academy of Orthopaedic Physical Therapy Associate Editor Orthopaedic Physical Therapy by 2920 East Ave So, Suite 200 Rita Shapiro, PT, MA, DPT La Crosse, Wisconsin 54601 fostering quality patient/client care 800-444-3982 x 2020 Book Review Editor and promoting professional growth. 608-788-3965 FAX Rita Shapiro, PT, MA, DPT Email: [email protected]

Publication Title: Orthopaedic Physical Therapy Practice Statement of Frequency: Quarterly; January, April, July, and October Authorized Organization’s Name and Address: Academy of Orthopaedic Physical Therapy, 2920 East Avenue South, Suite 200, La Crosse, WI 54601-7202

Orthopaedic Physical Therapy Practice (ISSN 1532-0871) is the official magazine of the Academy of Orthopaedic Physical Therapy. Copyright 2019 by the Academy of Orthopaedic Physical Therapy. Nonmem ber subscriptions are available for $50 per year (4 issues). Opinions expr essed by the authors are their own and do not necessar ily reflect the views of the Academy of Orthopaedic Physical Therapy. The Editor reserves the right to edit manuscripts as neces sary for publi cation. All requests for change of addr ess should be directed to the Academy of Orthopaedic Physical Therapy office in La Crosse. All advertisements that appear in or accompa ny Orthopaedic Physical Therapy Practice are accept ed on the basis of conformation to ethical physical therapy standar ds, but acceptance does not imply endorsement by the Academy of Orthopaedic Physical Therapy. Orthopaedic Physical Therapy Practice is indexed by Cumu lativ e Index to Nursing & Allied Health Literature (CINAHL) and EBSCO Publishing, Inc.

Orthopaedic Practice volume 31 / number 1 / 2019 1

6938_OP_Jan.indd 1 12/17/18 12:55 PM DIRECTORY 2019 / volume 31 / number 1

OFFICERS CHAIRS MEMBERSHIP AWARDS Megan Poll, PT, DPT, OCS Lori Michener, PT, PhD, ATC, FAPTA, SCS President: 908-208-2321 • [email protected] (See Vice President) Stephen McDavitt, PT, DPT, MS, 1st Term: 2018-2021 Members: Kevin Gard, Marie Corkery, FAAOMPT, FAPTA Members: Christine Becks (student), Thomas Fliss, Murray Maitland Molly Baker O'Rourke, Nathaniel Mosher 207-396-5165 • [email protected] JOSPT 2nd Term: 2016-2019 EDUCATION PROGRAM Guy Simoneau, PT, PhD, FAPTA Nancy Bloom, PT, DPT, MSOT [email protected] Vice President: 314-286-1400 • [email protected] Lori Michener, PT, PhD, SCS, ATC, FAPTA Executive Director/Publisher: 1st Term: 2016-2019 Edith Holmes 804-828-0234 • [email protected] 877-766-3450 • [email protected] 1st Term: 2017-2020 Vice Chair: Emmanuel “Manny” Yung, PT, MA, DPT, OCS NOMINATIONS Treasurer: 203-416-3953 • [email protected] Carol Courtney, PT, PhD, ATC Kimberly Wellborn, PT, MBA 1st Term: 2016-2019 [email protected] 1st Term: 2018-2019 615-465-7145 • [email protected] Members: Erick Folkins, Valerie Spees, Cuong Pho, John Heick, 2nd Term: 2018-2021 Kate Spencer Members: Brian Eckenrode, Michael Bade INDEPENDENT STUDY COURSE & Director 1: APTA BOARD LIAISON – ORTHOPAEDIC PRACTICE Robert Rowe, PT, DPT, DMT, MHS Aimee Klein, PT, DPT, DSc, OCS Editor: 813-974-6202 • [email protected] Christopher Hughes, PT, PhD, OCS, CSCS 2018 House of Delegates Representative – 2nd Term: 2018-2021 724-738-2757 • [email protected] Kathy Cieslak, PT, DSc, OCS Term ISC: 2007-2019 Director 2: Term OP: 2004-2019 ICF-based CPG Editors – Guy Simoneau, PT, PhD, FAPTA Duane “Scott” Davis, PT, MS, EdD, OCS ISC Associate Editor: [email protected] 304-293-0264 • [email protected] Gordon Riddle, PT, DPT, ATC, OCS, SCS 1st Term: 2017-2020 1st Term: 2016-2019 [email protected] Christine McDonough, PT, PhD 2nd Term: 2017-2020 [email protected] OP Associate Editor: 2nd Term: 2016-2019 Rita Shapiro, PT, MA, DPT RobRoy Martin, PT, PhD Explore the [email protected] [email protected] Academy of Orthopaedic 1st Term: 2017-2020 1st Term: 2018-2021 PUBLIC RELATIONS/MARKETING Physical Therapy Jared Burch, PT

Special Interest Groups website at: 908-839-5506 • [email protected] 1st Term: 2018-2021 orthopt.org OCCUPATIONAL HEALTH SIG Members: Tyler Schultz, Adrian Miranda, William Stokes, Lorena Pettet Payne, PT, MPA, OCS Derek Charles, Ryan Maddrey, 406-581-3147 • [email protected] Explore all the indepdendent Kelsea Weber (student) 2nd Term: 2016-2019

study courses (ISCs) we FOOT AND ANKLE SIG have to offer at: RESEARCH Christopher Neville, PT, PhD Dan White, PT, ScD, MSc, NCS 315-464-6888 • [email protected] orthopt.org 302-831-7607 • [email protected] 1st Term: 2016-2019 1st Term: 2016-2019 PERFORMING ARTS SIG Vice Chair: Annette Karim, PT, DPT, OCS, FAAOMPT Amee Seitz PT, PhD, DPT, OCS 626-815-5020 ext 5072 • [email protected] Office Personnel 1st Term: 2016-2019 2nd Term: 2017-2020  Members: Joshua Stefanik, Marcie Harris-Hayes, Sean Rundell, PAIN MANAGEMENT SIG Arie Van Duijn, Alison Chang, Louise Thoma Carolyn McManus, MSPT, MA 206-215-3176 • [email protected] (608) 788-3982 or (800) 444-3982 ORTHOPAEDIC SPECIALTY COUNCIL 1st Term: 2017-2020 Pam Kikillus, PT, DHSc, OCS, CHT, FAAOMPT Terri DeFlorian, Executive Director 253-709-8684 • [email protected] IMAGING SIG Term: Expires 2019 Charles Hazle, PT, PhD x2040...... [email protected] 606-439-3557 • [email protected] Tara Fredrickson, Executive Associate Members: Hilary Greenberger, Grace Johnson, 1st Term: 2016-2019 Judith Geller x2030...... [email protected] ORTHOPAEDIC RESIDENCY/FELLOWSHIP SIG Leah Vogt, Executive Assistant PRACTICE Matthew Haberl, PT, DPT, OCS, ATC, FAAOMPT Kathy Cieslak, PT, DScPT, MSEd, OCS 608-406-6335 • [email protected] x2090...... [email protected] 507-293-0885 • [email protected] 1st Term: 2018-2021 Sharon Klinski, Managing Editor 2nd Term: 2018-2021 ANIMAL REHABILITATION SIG x2020...... [email protected] Members: James Spencer, Marcia Spoto, Kirk Peck, PT, PhD, CSCS, CCRT Laura Eichmann, Publishing Assistant Mary Fran Delaune, Molly Malloy, Jim Dauber 402-280-5633 • [email protected] x2050...... [email protected] FINANCE 2nd Term: 2016-2019 Brenda Johnson, ICF-based CPG Coordinator Kimberly Wellborn, PT, MBA (See Treasurer) Education Interest Groups x2130...... [email protected]  Members: Doug Bardugon, Penny Schulken, Judith Hess PTA Jason Oliver, PTA [email protected]

6938_OP_Jan.indd 2 12/17/18 12:55 PM President’s All Good Things Must Come Corner to an End

It is hard to believe that 6 years of service • Publications: as your President has now come to the end. • Restructured and reorganized the Thank you for allowing me to serve you! I framing of the ISC and OP editors’ want to take this opportunity to share with contracts, responsibilities, and ac- you what WE have accomplished. countabilities. When elected in 2013, I came to the • Managed and coordinated the devel- • Added a new SIG: Orthopaedic Resi- Orthopaedic Section now Academy of Ortho- opment of the Independent Study dency/Fellowship SIG. paedic Physical Therapy (AOPT) with one Courses platform with JOSPT which • Developed a membership volunteer basic philosophy. This leadership opportunity has now further advanced to our own policy and format to enhance mem- granted to me by the members would not Learning Management System. bership access to participation in be about my personal accomplishments. It • Clinical Practice Guidelines: the development and completion of would be about me facilitating and enabling • Reorganized and restructured the Academy initiatives. volunteer experts to actively participate in the oversight of clinical practice guide- • Increased Advocacy Grants available in achievement of the mission and vision of the lines including the development of 2016 from $15,000 to $25,000. Academy. I appreciate that as President, lead- new guidelines, revising guidelines, • Developed a new Career Development ing and developing teambuilding is certainly and implementation of guideline Grant. important but sometimes driving the bus just products. • Home Office: plainly means taking a backseat. Within that • Executed an ICF-based CPG coordi- • Staff: Expanded the existing Academy viewpoint I basically believed that my position nator. staff to include an Executive Assistant, was to lead with a collaborative philosophy, • Facilitated the development, design, Publishing Assistant, and ICF-based absent of personal agendas with openness of and coordination of Clinical Practice CPG Coordinator. bias and to follow with collective actions that Guidelines into the structuring of • Real Estate Management: Coordinated would excel the Academy in practice, educa- modules for the APTA Physical Ther- and completed a new HVAC system tion, research, and advocacy. Such initiatives apy Registry. and restructuring of rental agreements were always framed by integrity, professional- • Board of Directors Functionality: and rental space to enhance the stabil- ism, and orthopaedic clinical science. My goal • Enhanced the Board of Directors ori- ity of real estate value and revenue. then as I saw it was to facilitate opportunities entation program. This includes ori- It is important to note that none of these for members to participate in the dynamic entation and exit interviews. accomplishments could have been achieved development and enhancement of the AOPT. • Restructured and enhanced the pre- without member feedback; our collaborative I feel that goal was accomplished across all our sentation and organization of meeting management from the AOPT Board of Direc- outcomes. I deeply and sincerely thank all of agendas. tors; and the time, energy, and efforts from our you who have taken any opportunity to serve, • Restructured and enhanced the orga- exceptional operations staff. I encourage all of for your personal dedication, sacrifices, and nization and presentation of finance you to go to the AOPT website and look at the compromises on behalf of the AOPT. and budgeting reports. different programs we offer our members and So, what have WE accomplished in the • Assessed and structured the proposal the framework of members and staff who par- past 6 years? Here’s a sample of some of the for expanding the Board of Directors ticipate in making those programs successful. many initiatives and actions: to enhance their ability to manage the Again, I THANK ALL OF YOU for all those • Annual Orthopaedic Meeting (AOM): growing workload of the Academy. accomplishments. • Advanced the development of AOM • Branding and Identity: What about the next steps? That, of course, in accordance with the members • Reviewed, directed, and completed a will be up to your new President. Since this is needs and feedback. This included re- launching of a Branding/Marketing your Academy, I hope you will step up to the structuring the meeting and the topics Campaign. plate and help your new President continue to within the meetings. • Examined, assessed, and implemented move the Academy forward with your vision, • Adapted and modified our advanced a name change to the Academy of Or- ideas, and efforts since the future of the Acad- clinical meeting philosophy by in- thopaedic PhysicalTherapy emy is up to the membership assisting the cluding students and physical thera- • Program Development: Board of Directors. I know I will, and I hope pist assistants in accordance with their • Enhanced member growth. to see you there! competencies. • Updated all courses in the Residency Again, many thanks for your encourage- • Added an AOM Director whose Curriculum. ment and support during this opportunity to objective is help orchestrate and co- • Provided opportunities for the ad- serve you as your President. ordinate the annual meeting with vancement of the PTA SIG. independent study courses, content • Developed the framework for the Sincerely, experts, and our other educational APTA PTA Advance Proficiency Path- Stephen McDavitt, PT, DPT, MS, programming. ways Program in Orthopedics. FAAOMPT, FAPTA

Orthopaedic Practice volume 31 / number 1 / 2019 3

6938_OP_Jan.indd 3 12/17/18 12:55 PM THE SHOULDER Independent Study Course 28.2

Learning Objectives Topics and Authors 1. Understand shoulder biomechanics and pathomechanics. Clinical Kinesiology of the Shoulder Complex: Foundations for 2. Understand the components of a thorough physical exam- Therapeutic Exercise—Phil Page, PhD, PT, ATC, CSCS, FACSM ination in the diagnosis of rotator cuff tears. 3. Describe the evidence supporting a framework for prescrib- Evaluation and Treatment of the Rotator Cuff—Craig Garrison, ing therapeutic exercise for shoulder dysfunction. PT, PhD, ATC, SCS; Joseph Hannon, DPT, PhD, SCS, CSCS; 4. Understand the specifi c etiology and pathology involved in Dean Papaliodis, MD rotator cuff tears. Evaluation and Treatment of the Stiff Shoulder—Nancy Hen- 5. Describe the rationale for nonoperative and operative derson, PT, DPT, OCS; Ryan Decarreau, PT, DPT, SCS, ATC, CSCS; treatment of rotator cuff tears. Haley Worst, PT, DPT, OCS; Jay B. Cook, MD 6. Describe appropriate rehabilitation interventions in the early, middle, and late stages following rotator cuff repair Management and Treatment of the Anterior Shoulder Insta- surgery. bility—Charles A. Thigpen, PT, PhD, ATC; Lane N. Rush, MD; 7. Describe the risk factors for development of shoulder stiff- Sarah Babrowicz, BS; Richard J. Hawkins, MD, FRCS(C); Michael ness and differential diagnosis. J. Kissenberth, MD 8. Describe the current evidence for nonsurgical management of shoulder stiffness and specifi c physical therapy Return to Performance: Baseball Athletes and Throwing Pro- interventions. grams—Ellen Shanley, PT, PhD, OCS; Thomas J. Noonan, MD; 9. Understand the natural history for adhesive capsulitis and Susan Falsone, PT, MS, SCS, ATC, CSCS, COMT, RYT® key concepts in the prevention of postoperative stiffness. A Functional Testing Algorithm for Returning Patients Back 10. Describe principles, goals, and quantitative measures of to Activity progression in the nonoperative rehabilitation for shoulder —George J. Davies, PT, DPT, MEd, SCS, ATC, LAT, instability. CSCS, PES, FAPTA; Eric Hegedus, PT, DPT, PhD, OCS; Matthew 11. Understand advantages and indications for surgical Provencher, MD; Robert C. Manske, PT, DPT, SCS, ATC, CSCS; methods to correct shoulder instability. Todd S. Ellenbecker, PT, DPT, MS, SCS, OCS, CSCS 12. Identify criteria to return to desired activity following a postoperative rehabilitation program. Continuing Education Credit 13. Discuss the structure and criteria for rehabilitation progres- 30 contact hours will be awarded to registrants who sion governing return to sport for the overhead athlete. successfully complete the fi nal examination. The Orthopaedic 14. Identify appropriate return to play progression modifi ca- Section pursues CEU approval from the following states: tions to accommodate for workload variations and seasonal Nevada, Ohio, Oklahoma, California, and Texas. factors. Registrants from other states must apply to their 15. Compose a functional testing algorithm for return to activi- individual State Licensure Boards for ty based on patient expectations. approval of continuing education credit.

Editorial Staff Course content is not intended for Christopher Hughes, PT, PhD, OCS, CSCS—Editor use by participants outside the Gordon Riddle, PT, DPT, ATC, OCS, SCS, CSCS—Associate Editor scope of their license or Sharon Klinski—Managing Editor regulation. Description This 6-monograph series addresses the biomechanical, pathological, and evaluative aspects of treating the shoulder. Speciﬁ c emphasis is placed on the rotator cuff, shoulder instability, and special concerns for the overhead athlete. Therapeutic exercise and return to activity considerations are discussed in detail as well. Decision making and treatment plans for nonoperative and operative scenarios are highlighted. All authors have extensive experience in the evaluation and management of shoulder pathology.

For Registration and Fees, visit orthopt.org Additional Questions—Call toll free 800/444-3982

4 Orthopaedic Practice volume 31 / number 1 / 2019

6938_OP_Jan.indd 4 12/17/18 12:55 PM Making Something from Editor’s Note Nothing Christopher Hughes, PT, PhD, OCS, CSCS

The year was 2004. That’s right the same correct details! She knew what I needed even year Facebook launched. This was the year before I did. My very own Radar O’Reilly. I came aboard as Editor of OPTP. My title You youngsters can look that reference up. “Making Something from Nothing” reflects Sharon, I can’t thank you enough for being the task and excitement I have had since 2004. in the trenches with me and teaching me how We knew that and always tried to be “pub- Every issue of OPTP was a blank canvas that to mix the colors and paint the canvas every lish friendly.” In the end, the Editors always had the allure of creating something where issue. Thank you so much. strived to present each article and effort in nothing existed, an empty landscape. I really I also want to thank Dr. Chris Carcia the best light for every author. I hope we did loved it when an issue came together. There who graciously served as Associate Editor that. Once again, I extend a heartfelt thank has been no greater thrill than finishing final from 2015-2016. Dr Carcia was painless to you to ALL the authors. Without your sub- copy and seeing the nothing become some- work with and really got us through some missions and patience throughout the editing thing! I honestly cannot say what spurred me busy times. I also want to express apprecia- process, I would not have lasted this long. To to apply for the job in 2004 but I am so fortu- tion to Michael Wooden for all his work in future contributors; if you are even ponder- nate to have acted on the urge and ultimately administering the book reviews through the ing about submitting an article, please send it be offered the job. For the past 15 years I had years. My appreciation also extends to cur- in and keep them coming! The best feeling as the privilege of working with the great staff rent Associate Editor, Rita Shapiro who an Editor is to have a healthy supply of great at the home office in La Crosse, WI. Get- stepped in to oversee the reviews upon articles to publish. ting to know and closely work with wonder- Michael’s retirement. Rita has also edited sev- Lastly, I would like to welcome the new ful people who keep the Academy going has eral submissions and has been a valued asset Incoming Editor, John Heick. I am confident been a real blessing. I learned so much about in sharing the workload and upholding the John will do a great job moving things for- organizational administration, the publica- editorial standard. I also cannot leave out our ward and leaving his own editorial mark in tion process, and also that La Crosse has a Advertising Coordinator Marilyn Brodsky… advancing OPTP. He is well-qualified and is reputation for cranberries! Seeing firsthand Marilyn always came through for us even vested in promoting a quality product. how hard our talented team members (Terri, during tough advertising cycles. She just had OPTP is what it is. I am proud to have Tara, Leah, Brenda, Laura, Sharon) work a knack for securing great ads for Sharon to served as Editor for the past 15 years. OPTP to make sure the home base stays in order work with to fill each issue. So take all this is a publication that represents the pulse of its year after year and from one administration effort and talent and inevitably, what the readers and has a unique place in providing to another is impressive. That standard was reader is left with every quarter is a product newsworthy and informative content. I am always something the editorial staff tried to that reflects dedication and a passion that was going to take a nap now. ingrain into each OPTP publication. truly teamwork personified. Again, an Editor Thank you for the privilege, Of course there has been no one better to could not have asked to work with more tal- partner with in enforcing this standard and ented people! All that was right was because filling the blank canvas every quarter than of them and anything that was errored was my Managing Editor, Sharon Klinski. I had solely my oversight. the best front row seat to watch the amazing My sincere gratitude and appreciation talents of how Sharon was able to edit, orga- also extends to the 3 Presidents I have served nize, and construct a first class publication under (Mike Cibulka, Jay Irrgang, and Steve every issue. If you have ever called the office McDavitt), their governing Board of Direc- and chatted with Sharon, you know what I tors and all the SIG leaders through the years. mean. A true professional who treats every A special callout to one of my first Board member with respect and sincerity. An excel- Liaisons, Dr. Tom McPoil. Their support lent Editor and a real class act we are lucky always enabled me to work effectively and to have. When you see the entire first draft efficiently. I could not help but succeed with and how it transforms to a polished publi- all of these talented people behind me. cation you gain a real appreciation for how The other special group that trademarks much pride it takes to dedicate the hours to OPTP is all the authors through the years! the painstaking detail that always resulted in Honestly, you all have been wonderful to a readable and informative work. That’s all work with. Many of the authors were first- on Sharon. I had a wonderful mentor for the time writers who had something to share but past 15 years and she always kept me orga- were not sure if they were worthy of putting nized and more importantly focused on the their ideas and findings into a publication.

Orthopaedic Practice volume 31 / number 1 / 2019 5

6938_OP_Jan.indd 5 12/17/18 12:55 PM New Year John Heick, PT, PhD, DPT New Editor

Hello, I want to introduce myself in this in Tucson, Arizona. You may remember PT ing OPTP inaugural editorial letter to those that do not magazine’s 2000 article regarding physical through the know me. I am a full-time physical therapy therapists in the emergency room. This was years through faculty member at Northern Arizona Uni- the same hospital that initiated PT in the our website, versity in Flagstaff, Arizona. My journey is emergency department 7 days a week (and just like I did. interesting and I will explain briefly. I origi- continue to do so). I soaked up as much as Amazing, Chris! nally became interested in health care as a 3rd I could from my colleagues and worked in My intention with OPTP is to continue grader when I witnessed my mom falling off multiple settings throughout the hospital to produce a clinician-friendly publication her bicycle and I felt a terrible helplessness. including their outpatient sports/orthopae- that benefits all who read OPTP. This past This memory stayed with me, and I enlisted dic clinic. It was a fantastic feeling to come fall, a survey was sent out to all Orthopaedic in the US Air Force soon after high school to work with colleagues querying each other Academy members to hear recommendations knowing that I wanted to be a physical thera- about the latest and greatest articles that they on future directions for OPTP. As Editor, I pist. I decided not to try to become a physical just read from JOSPT and OPTP. I had an intend to listen to you and make sure I do therapist assistant in the Air Force because at opportunity to teach nights at a local PTA my very best to produce what you want. Feel that time, a 6-year time commitment seemed program and I enthusiastically jumped on it. free to contact me with your comments or like a really long time. Instead, I became a I learned through this experience that I really suggestions. medic and after 2 years, I applied for the enjoyed education especially when students special duty assignment and became a flight had an epiphany on a topic that I was teach- Professionally, medic. As a flight medic, I would work in the ing and was suddenly able to apply this to a John Heick, PT, PhD, DPT back of a C-9 plane that was set up as a flying patient. My interest in education was sparked Board-certified in Orthopaedics, Sports, and hospital, with a capacity of 40 patients on while I attended an Arizona Physical Therapy Neurology gurneys and 40 ambulatory patients. Most Association state meeting and Jim Roush sug- months, I flew 12 to 15 days and basically gested I apply to teach at A.T. Still University lived out of a flight bag. It was a lot of fun, in Mesa, Arizona. Next thing I knew, I was as I would have breakfast in Maryland, lunch teaching 3 days a week in Mesa and working in Texas, and dinner in California. I attended in the clinic 3 days a week in Tucson. After classes on a part-time basis and worked my working and teaching for 12 years, I earned way to becoming a physical therapist. I soon my PhD in Orthopaedic and Sports Science learned that I needed to attend classes full- from Rocky Mountain University of Health time or it was going to take many years to Professions in Provo, Utah with my disser- reach my goal! I left active duty Air Force tation in concussion assessment. I returned after 5 ½ years and moved to Flagstaff, Ari- to Flagstaff 2 years ago to teach at Northern zona, to complete my bachelor’s degree and Arizona University after teaching for several entered the Air Force Reserves. Unlike other years in Mesa. Currently, I see patients in our undergraduate students attending Northern pro bono clinic and I work per diem in an Arizona University, I performed my flight orthopaedic outpatient clinic. medic duties by driving to March Air Force I have the pleasure and the pressure of fol- Base in Riverside, California, then flying to lowing Dr. Chris Hughes as Editor of OPTP. and from Hickam Air Force Base in Oahu, Chris has been the Editor of OPTP since Hawaii for the weekend and then driving 2004 and has done an amazing job. When I back to Flagstaff on Sunday in the wee hours first saw that the position was open, I called of the night. They were long weekends but I Chris. We had a great conversation in which enjoyed having my military connection con- he told me as much as possible about the tinue while learning about exercise physiol- position and what it entailed; he encouraged ogy and anatomy during the week. I got into me to apply for the Editor position. When I Shenandoah University’s Physical Therapy interviewed for the Editor position, I reviewed program and graduated with my Master’s OPTP articles starting from the first volume degree. My class was the last Master’s class so and then every 5 years thereafter to get a feel I jumped into the transitional DPT program for the Editor, the journal, and the progres- as soon as I completed my Master’s and in the sion of OPTP. Since the beginning of OPTP, meantime, since my wife is from Arizona, we Dr. Hughes’ tour as an Editor represents 33% moved back to Arizona. I started my physi- of the time that OPTP has been published! cal therapy career at St. Joseph’s Hospital His efforts can be viewed by all by review-

6 Orthopaedic Practice volume 31 / number 1 / 2019

6938_OP_Jan.indd 6 12/17/18 12:55 PM PHARMACOLOGY PHARMACOLOGYIndependent Study Course 28.4 Learning Objectives DescriptionIndependent Study Course 28.4 1. Understand the pathophysiology of common cardiovascular Pharmacology plays a signifi cant role in administering physical conditions as relevant to the pharmacological management therapy to a patient. Clinicians must be aware of not only what Learningof those Objectives conditions. Descriptionmedications patients are taking but also the impact these drugs 1. Understand2. Identify the drug pathophysiology classes used to of treat common common cardiovascular cardiovascular Pharmacologyhave on plays the a neuromusculoskeletal signifi cant role in administering system. Thisphysical series covers conditionsconditions, as relevant including to the heart pharmacological failure, angina management pectoris, myocar- therapy tothe a patient.most common Clinicians knowledge must be aware needed of notto effectively only what understand of thosedial conditions. infarction, arrhythmia, hypertension, and blood clot. medicationsissues patients for common are taking cardiovascular but also the impact conditions, these diabetesdrugs mellitus, 2. Identify3. Describe drug classes the mechanism used to treat of actioncommon for cardiovascular each drug class used have on theand neuromusculoskeletal the management of pain. system. There This are series two covers unique aspects in conditions,in the treatmentincluding heart of a failure,cardiovascular angina pectoris, condition myocar- and its rele- the mostthis common series. knowledge The fi rst isneeded a re-issue to effectively of a popular understand and previously dial infarction, arrhythmia, hypertension, and blood clot. issues for common cardiovascular conditions, diabetes mellitus, vance to the pathophysiology of the condition. offered monograph (bonus) that reviews the principles of 3. Describe the mechanism of action for each drug class used and the management of pain. There are two unique aspects in 4. Describe the interaction between pharmacology and physi- pharmacotherapeutics. This monograph serves as an introduc- in the treatment of a cardiovascular condition and its rele- this series. The fi rst is a re-issue of a popular and previously cal therapy in the treatment of common PHYSICALcardiovascular tionTHERAPY for those readers who may not be familiar with pharmaco- vance to the pathophysiology of the condition. offered monograph (bonus) that reviews the principles of conditions. therapeutics or can serve as a comprehensive review for those 4. Describe the interaction between pharmacology and physi- pharmacotherapeutics. This monograph serves as an introduc- cal5. therapy Understand in the treatmentthe pathophysiology of common cardiovascularof diabetes mellitus,MANAGEMENT tion for thosewho havereaders a previous who may education notOF be familiar on the with topic. pharmaco- The second is an conditions.including the differences between Type 1 and Type 2. therapeuticsaudio-based or can serve PowerPoint as a comprehensive presentation review that for adds those a dynamic 5. Understand6. Identify the oral pathophysiology and injectable ofanti-diabetic diabetes mellitus, drug classes used CONCUSSIONwho haveelement a previous to theeducation coverage on theof pharmacology topic. The second and is pain an management. includingto treat the Typedifferences 2 diabetes between mellitus Type and1 and their Type mechanism 2. audio-basedDr. Tinsley’s PowerPoint oral presentation presentation that and adds excellent a dynamic slide presentation 6. Identifyof actions. oral and injectable anti-diabetic drug classes used elementIndependent towill the engage coverage Study the oflistener pharmacologyCourse and 28.1 allow and her pain to management.share her enthusiastic to7. treat Understand Type 2 diabetes the side mellitus effects and of theirdrugs mechanism used to treat Type 2 Dr. Tinsley’sconversational oral presentation style. and Case excellent study presentations slide presentation are included to of actions.diabetes mellitus as relevant toLearning physical Objectives therapy. will engagereinforce the listener the Editorialdidactic and allow material. Staff her to share her enthusiastic 7. Understand the side effects of drugs 1.used Describe to treat the signs,Type symptoms, 2 biomechanics,conversational and pathophys- style. CaseChristopher study Hughes, presentations PT, PhD, OCS, are CSCS—Editor included to 8. Understand the relationship betweeniology ofinsulin a concussion. and exercise. Gordon Riddle, PT, DPT, ATC, OCS, SCS, CSCS—Associate Editor diabetes9. Understand mellitus as the relevant general to principles physical2. Cite therapy. of key pharmacology risk factors for sustaining as they a concussion reinforce and indicatorsContinuing the didactic material.Sharon Education Klinski—Managing Credit Editor 8. Understandrelate to the clinical relationship decision-making between insulin leadingand outcomes and to prolonged exercise. inrecovery the following concussion. Fifteen contact hours will be awarded to registrants who PHARMACOLOGY3. Describe common clinical profi les seen following concussion. 9. Understand the general principles of pharmacology as they Continuing EducationTopics and Credit Authors physical therapy management 4.of a Discuss patient. the role of biomarkers in the evaluation and manage-successfully completeThe Basics of the Concussion fi nal examination. The Orthopae- relate to clinical decision-making and outcomes in the Fifteen contact hours will be awarded to registrants who 10. Identify theIndependent important componentsment Study of of pharmacotherapeutic concussion. Course 28.4 dic Section pursuesAnne Mucha, CEU PT, approval DPT, MS, NCS from the following states: physical therapy management of a patient.5. Understand negative consequences ofsuccessfully poor concussion complete theCara fiTroutman-Enseki, nal examination. PT, DPT, The OCS, Orthopae- SCS principles as they relate to all populations and their impact Nevada, Ohio, Oklahoma, California, and Texas. Registrants 10. Identify the important components of pharmacotherapeuticmanagement. dic Section pursues CEU approval from the following states: on the physical therapy management6. Describe of aimportant patient. guidelines for return to play followingfrom other statesPhysical must Therapy apply Evaluation to their of Concussion individual State Licensure principles as they relate to all populations and their impact Nevada, Ohio, Oklahoma, California, and Texas. Registrants sport-related concussion. PHARMACOLOGYBoards for approvalAnne Mucha, of continuingPT, DPT, MS, NCS education credit. Learning Objectives Descriptionon the physical therapy management7. of Discussa patient. the advantages and disadvantagesfrom of various other concus- states mustCara apply Troutman-Enseki, to their individual PT, DPT, OCS, State SCS Licensure Topics and Authors sion prevention strategies. Boards for approvalIndependent of Timcontinuing Ryland, PT, Studyeducation EdD(c), MPT, Course OCS,credit. CBIS 28.4 1. Understand the pathophysiology of common cardiovascular Pharmacology plays a signifi cant role8. Select in administeringevidence-based tools physicaland outcome measuresCourse for content is not intended for use by participants conditions as relevant to the pharmacological management TopicstherapyPharmacological and to a patient.Authors Management Clinicians must for Cardiovascularclinical be aware evaluation of and Conditionsnot treatment only of what concussion. Advanced Concussion Management 9. Apply key examination and assessment methodsCourse for content cervical/outside is the not scope intended of their for use license by participants or regulation. PharmacologicalMelissa Bednarek, Management PT, DPT, for PhD, Cardiovascular CCS Conditions Anne Mucha, PT, DPT, MS, NCS of those conditions. medicationsLearning patients Objectives are taking but thoracicalso the spine, impact vestibular/oculomotor these drugs system,Descriptionoutside and theexertion scope of theirCara license Troutman-Enseki, or regulation. PT, DPT, OCS, SCS Melissa Bednarek, PT, DPT, PhD, CCS following concussion. 2. Identify drug classes used to treat common cardiovascular have1.Phramacological on Understand the neuromusculoskeletal the Managementpathophysiology for of common Diabetessystem. cardiovascular ThisMellitus series coversPharmacology plays a signifiTim cant Ryland, role PT, in EdD(c), administering MPT, OCS, CBIS physical conditions as relevant to the pharmacological10. Appreciate management the role of neurocognitive testingtherapy in concussion to a patient. Clinicians must be aware of not only what PhramacologicalMelissa Bednarek, Management PT, DPT, for PhD, Diabetes CCS evaluation Mellitus and management. Continuing Education Credit conditions, including heart failure, angina pectoris, myocar- the mostof thosecommon conditions. knowledge needed to effectively understandmedications patients are taking but also the impact these drugs Melissa Bednarek, PT, DPT, PhD, CCS 11. Identify clinical profi les and treatment strategies for each Fifteen contact hours will be awarded to registrants dial infarction, arrhythmia, hypertension, and blood clot. issues2.Principles for Identify common ofdrug Pharmacotherapeutics classes cardiovascular used to treat common conditions,concussion cardiovascular subtype: diabetes cervical, vestibular,mellitus,have ocular, on mood,the neuromusculoskeletal mi- who successfully system. complete This theseries fi nal coversexamination. conditions, including heart failure, anginagraine, pectoris, and cognitive/fatigue. myocar- the most common knowledgeThe Orthopaedic needed to Section effectively pursues understand CEU approval from the 3. Describe the mechanism of action for each drug class used Principlesand(Reissued the management of Pharmacotherapeutics from ISC 16.1.1) of pain. There are two unique aspects in dial infarction, arrhythmia, hypertension,12. Describe and bloodimportant clot. indicators for returnissues to activity for following common cardiovascularfollowing states: conditions, Nevada, diabetesOhio, Oklahoma, mellitus, California, (Reissued from ISC 16.1.1) concussion. in the treatment of a cardiovascular condition and its rele- this3.Suzanne series. Describe TheL. Tinsley, the fi rst mechanism isPT, a PhD re-issue of action of for a each popular drug class and used previously and the management of pain.and Texas. There Registrants are two fromunique other aspects states must in apply Suzanne L. Tinsley, PT, PhD 13. Discuss the role of sleep in concussion management, and to their individual State Licensure Boards for vance to the pathophysiology of the condition. offeredin monograph the treatment of(bonus) a cardiovascular that reviews condition the and principlesits rele- of this series. The fi rst is a re-issue of a popular and previously Pharmacology for Pain employ interventions that can be used to modify sleep approval of continuing education credit. 4. Describe the interaction between pharmacology and physi- Pharmacologypharmacotherapeutics.vance to for the Pain pathophysiology This monograph of the condition.dysregulation. serves as an introduc-offered monograph (bonus) that reviews the principles of 4.(Audio-Aided Describe the PowerPoint interaction between Presentation) pharmacology14. Appreciate the and infl physi-uence of psychogenic factorspharmacotherapeutics. in concussion ThisCourse monograph content is not serves intended as anfor introduc-use (Audio-Aided PowerPoint Presentation) management. cal therapy in the treatment of common cardiovascular tionSuzanne forcal those therapy L. Tinsley, readers in the PT, treatment who PhD may of common not be cardiovascular familiar with pharmaco-tion for those readers whoby may participants not be outside familiar the with scope pharmaco- Suzanne L. Tinsley, PT, PhD 15. Describe common pharmacologic and non-pharmacologic of their license or regulation. conditions. therapeuticsconditions. or can serve as a comprehensivetreatment options review for specifi cfor symptoms those followingtherapeutics concussion. or can serve as a comprehensive review for those 5. Understand the pathophysiology of diabetes mellitus, who5.Editorial have Understand a previous Staff the pathophysiology education on of diabetesthe topic. mellitus, The second is anwho have a previous education on the topic. The second is an Editorialincluding Staff the differences between TypeDescription 1 and Type 2. audio-based PowerPoint presentation that adds a dynamic including the differences between Type 1 and Type 2. audio-basedChristopher PowerPoint Hughes, PT, PhD,presentation OCS,This CSCS—Editor monograph that adds series provides a dynamic in-depth coverage for the eval- Christopher6. Identify Hughes, oral and PT, injectablePhD, OCS, anti-diabetic CSCS—Editor drug classes used element to the coverage of pharmacology and pain management. 6. Identify oral and injectable anti-diabetic drug classes used elementGordon to Riddle, the coverage PT, DPT, ATC,of pharmacology OCS,uation SCS, andCSCS—Associate treatment and pain of concussion management. Editor by a physical therapist. The Gordon Riddle,to treat PT, Type DPT, 2 diabetes ATC, OCS, mellitus SCS, and CSCS—Associateauthors their are mechanism recognized Editor clinical experts in theDr. fi eld Tinsley’s of concussion oral presentation and excellent slide presentation to treat Type 2 diabetes mellitus and their mechanism SharonDr. Tinsley’sSharon Klinski—Managingof actions. Klinski—Managing oral presentation Editor Editor andmanagement. excellent The slide basic pathophysiology presentation underlyingwill engage concussion the listener and allow her to share her enthusiastic is presented and then coupled with essential and advanced exam- of actions. will 7.engage Understand the listener the side effects and allow of drugs her used to to share treat Type her 2 enthusiasticconversational style. Case study presentations are included to diabetes mellitus as relevant to physicalination therapy. techniques. Special emphasis is placedreinforce on examination the didactic of material. the cervical and thoracic spine as part of concussion assessment 7. Understand the side effects of drugs used to treat Type 2 conversational8. Understand style. the relationship Case study between presentations insulin and exercise. are included to and treatment. diabetes mellitus as relevant to physical therapy. reinforce9. Understand the didactic the general material. principles of pharmacology as they Continuing Education Credit relate to clinical decision-making and outcomes in the Fifteen contact hours will be awarded to registrants who 8. Understand the relationship between insulin and exercise. For Registration and Fees, visit orthoptlearn.org physical therapy management of a patient. successfully complete the fi nal examination. The Orthopae- For ForRegistration Registration and Fees,and Fees, visit orthopt.org Additionalvisit orthopt.org Questions—Call toll free 800/444-3982 9. Understand the general principles of pharmacology as they Continuing10. Identify the importantEducation components Credit of pharmacotherapeutic dic Section pursues CEU approval from the following states: Additional Questions—Call toll free 800/444-3982 relate to clinical decision-making and outcomes in the FifteenAdditionalprinciples contact as Questions—Call hoursthey relate will to be all populations awarded toll andfreeto registrantstheir 800/444-3982 impact who Nevada, Ohio, Oklahoma, California, and Texas. Registrants physical therapy management of a patient. successfullyon the physicalcomplete therapy the management fi nal examination. of a patient. The Orthopae- from other states must apply to their individual State Licensure Boards for approval of continuing education credit. 10. Identify the important components of pharmacotherapeutic dic Section pursues CEU approval from the following states: Orthopaedic Practice Topicsvolume and 31 / number Authors 1 / 2019 7 principles as they relate to all populations and their impact Nevada, Ohio, Oklahoma, California, and Texas. Registrants Course content is not intended for use by participants Pharmacological Management for Cardiovascular Conditions outside the scope of their license or regulation. on the physical therapy management of a patient. fromMelissa other Bednarek, states PT,must DPT, apply PhD, CCS to their individual State Licensure 6938_OP_Jan.inddBoards 7 for approval of continuing education credit. 12/17/18 12:55 PM Phramacological Management for Diabetes Mellitus Topics and Authors Melissa Bednarek, PT, DPT, PhD, CCS Course content is not intended for use by participants Pharmacological Management for Cardiovascular Conditions Principles of Pharmacotherapeutics outside the scope of their license or regulation. Melissa Bednarek, PT, DPT, PhD, CCS (Reissued from ISC 16.1.1) Suzanne L. Tinsley, PT, PhD

Phramacological Management for Diabetes Mellitus Pharmacology for Pain Melissa Bednarek, PT, DPT, PhD, CCS (Audio-Aided PowerPoint Presentation) Suzanne L. Tinsley, PT, PhD Principles of Pharmacotherapeutics Editorial Staff (Reissued from ISC 16.1.1) Christopher Hughes, PT, PhD, OCS, CSCS—Editor Suzanne L. Tinsley, PT, PhD Gordon Riddle, PT, DPT, ATC, OCS, SCS, CSCS—Associate Editor Sharon Klinski—Managing Editor Pharmacology for Pain (Audio-Aided PowerPoint Presentation) Suzanne L. Tinsley, PT, PhD

For Registration and Fees, visit orthopt.org Editorial Staff Additional Questions—Call toll free 800/444-3982 Christopher Hughes, PT, PhD, OCS, CSCS—Editor Gordon Riddle, PT, DPT, ATC, OCS, SCS, CSCS—Associate Editor Sharon Klinski—Managing Editor

For Registration and Fees, visit orthopt.org Additional Questions—Call toll free 800/444-3982 Effect of Eccentric Exercises at the Knee with Hip Muscle Kerry MacDonald, PT, DSc, OCS, Dip MDT1 Strengthening to Treat Patellar Jonathan Day, MA, CPO2 Tendinopathy in Active Duty Carol Dionne, PT, DPT, PhD, MS, OCS, Cert. MDT3 Military Personnel: A Randomized Pilot

1Staff Physical Therapist, Reynolds Army Health Clinic, Fort Sill, OK 2Clinical Associate Professor, Department of Orthopedic Surgery and Rehabilitation, Oklahoma City, OK 3Associate Professor, Department of Rehabilitation Sciences, University of Oklahoma Health Sciences Center, Oklahoma City, OK

ABSTRACT squat only group over a 24 week follow-up. activity of greater than or equal to 15 days5 to Background and Purpose: Tendinopa- The results suggest either treatment strategy 6 months6 in non-basic training soldiers. The thy is an over-use condition that results is likely to result in improvements when indirect cost of lost or reduced capabilities in painfully reduced exercise tolerance, treating an active duty military population. and additional manpower required to per- mechanical loading capacity, and function form the mission of an injured solider cannot negatively impacting soldiers and mission Key Words: eccentric decline squat, hip be calculated, but given the median time of readiness. Investigation of conservative treat- strengthening, patellar tendinopathy up to 6 months of reduced physical capabili- ment options is critical to facilitate mission ties, the burden is considered substantial. readiness. The purpose was to evaluate and Tendinopathy is an over-use condition Identifying pain generators in patellar compare clinical outcomes (pain and func- that results in painfully reduced exercise tendinopathy is arduous, with little-to-no evi- tion) following eccentric training (decline tolerance, mechanical loading capacity, and dence of inflammatory cells in the tendon.9,10 squats) with and without the addition of function.1 Clinical management of tendi- Pain has been postulated to arise from neo- proximal hip strengthening exercises. Meth- nopathy can be challenging because current vascularization,11-13 chemical irritants such ods: Forty-one activity duty soldiers (mean treatments fail to return athletes to competi- as prostaglandins or neurotransmitters,14,15 age 29.3 years, range 19-38) with patella tive sport.2 Such mediocre results can lead to central/peripheral sensitization,16,17 and tendinopathy were randomized to a stan- submaximal performance and forced retire- mechanical loading.1,18 Thus, prescribing dard of care (SOC) group (n=17) or treatment.3 Patellar tendinopathy is of particular the correct treatment is daunting. Larsson ment group (n=14). Intervention: The SOC interest to the military, as persistent symp- et al19 reviewed treatments for patellar tendi- group performed unilateral 25° eccentric toms with running and jumping can nega- nopathy which included exercises, injections squats (3 sets of 15 repetitions, 2 times per tively impact soldiers and overall mission (corticosteroid and sclerotic agents), extra- day) for 12 weeks. The treatment group per- readiness. Investigation of conservative treat- corporeal shock wave therapy, and surgery formed the same exercises plus concentric ment options in this population is critical to and concluded that “physical training, par- hip strengthening (3 sets of 10 repetitions, foster cost-effective mission readiness. ticularly eccentric exercises”19(p1632) should be 3 times per week) for 12 weeks. Findings: Accurate prevalence data for patellar ten- the first line of treatment. We found no significant differences between dinopathy within the active duty military Eccentric exercises effectively reduced groups for any of the outcome measures. We population is unknown. However, 15.1% pain and improved function in the patellar observed significant within group differences of musculoskeletal complaints in a Marine tendon12,19–25 for only 50% to 70% patients for all outcome measures. The LEFS SOC basic training group were classified as patellar studied.2 Perhaps treatment did not include increased from 57.7 to 66.8 (p=0.008) and tendinitis.4 Of all exercise and sport-related hip muscle strengthening which can also the treatment LEFS increased from 54.8 to injuries, 11.8% were classified as tendinitis/ influence knee kinematics. Individuals with 64.8 (p=0.007) at 24 weeks. The VISA-P bursitis.5 Tendinitis implies an active inflam- patella tendinopathy demonstrated dimin- SOC increased from 51.7 to 70.4 (p=0.001) matory process; whereas, tendinopathy sig- ished (27%) hip extensor strength26 and and the treatment group increased from nifies a generalized pathology in the tendon reduced peak knee and hip flexion with jump- 51.8 to 72 (p=0.002) at 24 weeks. Both that includes tendinitis and tendinosis. ing27 causing a sharply increased quadriceps groups reached minimal clinical important Determination of the prevalence of either demand28 leading to mechanically-induced difference (MCID) for LEFS and VISA-P condition appears elusive. Additionally, 41% tissue failure. When hip extensor strengthen- at 24 weeks. Clinical Relevance: Soldiers of all injuries requiring restricted duty were ing was combined with jump landing modi- may want to consider the addition of hip due to anterior knee pain.6 Anterior knee fication during an 8-week intervention, a strengthening as a feasible intervention for pain is an all-encompassing term used to volleyball player with a 9-month history of the treatment of patellar tendinopathy. Con- describe symptoms around the front of the patellar tendinopathy experienced a substan- clusion: Favorable effects were demonstrated knee, which due to its general symptomology tial decrease in pain.29 Frontal plane move- with patellar tendinopathy using either a may include patellar tendinopathy.7,8 Over- ments of the femur can alter the line of pull combined treatment of eccentric squat and use injuries such as patellar tendinopathy of the quadriceps. Increased hip adduction hip muscle strengthening or SOC eccentric result in a median time of limited or reduced during walking and running gait30 produces a

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6938_OP_Jan.indd 8 12/17/18 12:55 PM valgus-directed force at the knee. Hip abduc- tive data were collected on all participants as muscle strengthening exercises similar to the tor weakness is associated with increased well as hours participating in fitness activi- protocol described by Fukuda et al.34 Both valgus force produced at the knee during ties (organized or unorganized). Participants groups received written instructions on how jumping31 and step-downs.32 With altered completed the LEFS and VISA-P question- to construct a 25° decline squat board. Exer- knee joint kinematics reported in the sagittal naires and VAS for pain with activity. Par- cise progression was based on the pain moni- and frontal planes during walking, running, ticipants performed the single leg hop and toring system35 whereby pain up to 5/10 on jumping, and step-downs, it is plausible that triple hop distance testing described by numeric pain rating (NPR) was considered adding hip muscle strengthening to treat Noyes et al.33 Three hops were completed acceptable to minimize risk of tissue overload patellar tendinopathy may enhance existing on the symptomatic lower extremity and while facilitating a treatment effect. treatment outcomes. non-symptomatic lower extremity, with the All treatments were conducted by the The purpose of this pilot study was to longest distance recorded as the actual dis- same physical therapist. During the course evaluate active duty personnel with patel- tance hopped. For participants with bilateral of treatment, participants were allowed to lar tendinopathy and compare clinical symptoms, the right lower extremity was continue with their typical fitness routine outcomes (ie, pain rating and function) fol- recorded as the symptomatic side for con- using the pain monitoring model35 described lowing eccentric knee extensor training with sistency. Participants were randomized using where pain should not exceed 5/10 with any or without proximal hip strengthening. We sealed opaque envelopes to either a SOC or activity. Participants were instructed in the expected participants in the treatment (hip a treatment group (Figure 1). If a participant use of an exercise log to measure adherence. strengthening) group would significantly had bilateral patellar tendinopathy, both Participants were seen weekly during the first show improved outcome measures over the tendons were treated; however, each tendon month to ensure correct exercise technique standard-of-care (SOC) group that only per- was treated with the same intervention. The and progression. After the first month, treat- formed eccentric knee extensor training. SOC group performed unilateral eccen- ment frequency was based on participant tric decline squat.20,23 The treatment group progression and understanding of instruc- METHODS received identical care plus concentric hip tions. The LEFS, VISA-P, VAS for pain with Study Design This pilot study assessed and compared outcomes of unilateral, eccentric 25° decline squats combined with hip muscle strengthening for the treatment of patellar tendinopathy on participants’ functional status and pain rating, using the lower extremity functional scale (LEFS), Victorian Institute of Sport Assessment – Patella (VISA-P), Visual Analog Scale (VAS) for pain and jump distance with single-leg and triple-hop tests. This study was approved by the Brooke Army Medical Center Institutional Review Board, San Antonio, Texas.

Setting and Participants Participants were recruited from primary care, physical therapy, and orthopedic clinics at Ft. Sill, Oklahoma. Inclusion criteria were: age older than 18 years; reported > 3 months’ history of anterior knee pain with jumping, squatting, running and/or steps/stairs; palpable pain over the patella tendon; VISA-P score < 75; and in active duty service with at least 6 months’ time remaining at current duty station. Exclusion criteria were: VISA-P score > 75; reported pain with prolonged sitting or retropatellar pain; history of knee surgery; reported or radiographic evidence of knee osteoarthritis; rheumatic disease; neuromuscular or cardiovascular disease; diabetes; and pregnancy.

Procedures and Interventions Participants with anterior knee pain were screened for inclusion and exclusion criteria. After obtaining informed consent, descrip- Figure 1. Study flow diagram.

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6938_OP_Jan.indd 9 12/17/18 12:55 PM activity, and hop testing were administered by the same therapist performing treatment. All outcome measures were conducted at baseline, 4, 8, 12, and 24 weeks. Participants were instructed to continue with their exercise program between 12 and 24 weeks, but were not seen in physical therapy. They were not prohibited from seeking additional or alternative care.

Outcome Measures The LEFS is used to evaluate lower extremity musculoskeletal conditions (score 0-80, higher score indicative of high function).36 The VISA-P is a patella tendinopathy-specific questionnaire, used to evaluate an athlete’s symptom severity and function (0-100, higher scores indicate less symptoms/higher function).37 The VAS for pain with activity is a 10 centimeter line with two anchors. The left anchor is marked as no pain and the right anchor is marked worst pain possible.38 All are considered reliable and valid outcome measures.

Data and Statistical Analysis Descriptive analysis was conducted on participant anthropometric and symptomatic data. Independent t-tests assessed difference between groups. A two factor ANOVA (treatment, time) with repeated measures on one factor followed by post hoc least mean squares tests was used to determine differ- Figure 2. Standard of care and treatment protocols. ences from baseline to follow-up within and between groups for LEFS, VISA- P, VAS for pain with activity, and jump testing. pants were lost in the SOC and treatment 0.002) over 24 weeks, but no significant dif- Sample size estimation/power analysis groups. At 24-week follow-up, there were 3 ferences between groups were observed at 4, Using the LEFS outcome, based on the additionally lost in the standard group (30% 8, 12, or 24 weeks (Tables 2, 3, and 4; Fig- effect size in this pilot we found that to deter- total loss) and 3 additional in the treatment ures 3 and 4). The mean baseline LEFS scores mine a difference in these protocols, another group (43% total loss). The last known data were 57.7 for the SOC group and 54.8 for the study using an alpha = 0.05 and a beta = points were not carried forward with partici- treatment group (p=0.53). The mean baseline 0.80, would require a total of 1,134 and pants lost to follow-up, as the LEFS, VISA-P, VISA-P scores were 51.7 for the SOC group 592 participants at 12 and 24 weeks, respec- and VAS for pain with activity all include ele- and 51.8 for the treatment group (p=0.99). tively. Similarly, using the VISA-P outcome ments of pain. If participants were improved At 12 weeks, the mean LEFS and VISA-P for 1,468 and 4,228 subjects would be required and the last known data were carried forward, the SOC group were 66.2 and 67.3 result- at 12 and 24 weeks. When we designed this results could be skewed to underestimate or ing in an 8.5 (p=0.002) and 15.6 (p=0.002) pilot study, we anticipated a larger effect overestimate progress. Of 31 participants, point increase. By 24 weeks, the increase in size; therefore, the study was underpowered 14 returned exercise logs. Standard-of-care LEFS from baseline was 9.1 and VISA-P was at 0.058 and 0.053 for the LEFS and the group returned 5 logs with an average adher- 18.7 points. At 12 weeks, the mean LEFS and VISA-P at 24 weeks, respectively. ence rate of 42.5% of prescribed exercises VISA-P for the treatment group were 64 and over 12 weeks. In the treatment group, 9 63.8 resulting in a 9.2 (p=0.018) and 12.1 Results logs were returned with participants report- (p=0.102) point increase. By 24 weeks, the Forty-six participants were screened for ing 50% adherence with eccentric squat and increase in LEFS from baseline was 9.6 and inclusion and 31 were enrolled and random- 62% adherence with hip muscle strengthen- VISA-P was 20.2 points. Importantly, a direct ized (17 to the standard-of-care group and ing exercises over 12 weeks. strength measure such as manual muscle test 14 to the treatment group; Figure 2). Demo- Both groups recorded significantly grading or dynamometry was not measured. graphics, anthropometric, and symptomatic improved outcome measures of LEFS (stan- These measures could have been correlated baseline data were similar between groups dard p = 0.008, treatment p = 0.007) and with the functional outcome data. This lack (Table 1). At 12-week follow-up, 2 partici- VISA-P (standard p = 0.001, treatment p = of strength data may have limited the study

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6938_OP_Jan.indd 10 12/17/18 12:55 PM Table 1. Participant Characteristics at Baseline (Mean ± SD, Range) tension/load of the patellar tendon potentially impairing recovery. Performance of hip

Standard Treatment extension and abduction requires a concomi- (n=17) (n=14) p tant isometric contraction of the quadriceps Age (years) 31.3 ± 5.6 26.9 ± 7.4 0.070 muscle, mechanically loading the patellar (22.1-38) (19.7-42.3) tendon. Cook et al18 emphasize appropri- Weight (kilograms) 92.2 ± 13.6 88 ± 14.8 0.414 ate load management to facilitate recovery (74.2-132) (63.4-110) when managing tendinopathy. Sport speci- Height (centimeters) 178.7 ± 7.8 176.9 ± 10.2 0.573 ficity of the VISA-P offers another possible (164-193) (156-192) reason for lack of significant improvement in Symptom duration (months) 6.4 ± 3.3 15.3 ± 22.1 0.111 the treatment group. Soldiering tasks differ (3-12) (3-84) from sporting activities. Using a soldier task- Average hours in sports per week 7.1 ± 3.5 9.1 ± 3.9 0.146 specific outcome measure would likely alter (3-18) (0-15) results. Average miles ran per week 6.8 ± 5.5 7.9 ± 5.9 0.600 Another potential reason for lack of (0-15) (0-16) improvement with hip strengthening may be because hip strengthening does not address Number of female participants 1 1 kinematic deficits. Patellofemoral literature Number with bilateral symptoms 3 4 suggests hip strengthening helps reduce Note: Significant at p < 0.05 pain and improve function, but does not result in kinematic changes.40-43 Hip weakness is less pronounced in males than females with patellofemoral syndrome44; therefore, findings and interpretation of the data. concentric hip muscle strengthening over strengthening of hip musculature results in The VAS for pain with activity scores were traditional SOC exercises (eccentric squat) the greatest improvements in women.42 The significantly reduced over 24 weeks for the for the treatment of patellar tendinopathy present study included primarily males. Hip treatment group (p= 0.013) and trended a over a 24 week follow-up in an active duty strengthening is likely more appropriate reduction for the standard group (p = 0.052), military sample. Outcome measures of LEFS when treating females with this condition. but no significant difference between groups and VISA-P significantly improved in both This is the first study to investigate patel- were observed at 4, 8, 12, or 24 weeks (Table groups over time. Each group attained mini- lar tendinopathy in a military population 4 and 5, Figure 5). Single-leg triple hop dis- mal clinically important difference (MCID) and combined hip muscle strengthening tance was not different within or between for each outcome measure at 24 weeks. The with SOC exercises. While the results did groups at 4, 8, 12, or 24 weeks. Triple hop LEFS improved by 9.2 points in the SOC not favor one treatment over the other, the distance was significantly different within group and 9.6 points in the treatment group treatment group resulted in less reported the standard group between 4 and 12 weeks (MCID 9).36 The VISA-P scores improved pain with activity and better improvement in (p=0.044). Outcomes were similar among by 18.7 points in the SOC group and 20.2 VISA-P scores at 24 weeks. Soldiering tasks and between groups at 4, 8, 12, or 24 weeks points in the treatment group (MCID 13).39 place significant stress on the patellar tendon. (Tables 6-9). The VAS for pain with activity reduced by Army physical readiness training, is con- 1.3 points in the standard group and 2.2 ducted 5 days per week,45 and involves plyo- DISCUSSION points in the treatment group (MCID 1.3).38 metric training, running, agility, and general In contrast to the original expectation, One explanation for lack of improvement strengthening activities. Some military occu- the present trial showed no favorable effects with the addition of hip strengthening may pational specialties require heavy lifting while of combined treatment of eccentric squat and be attributed to disproportionate time under wearing tactile gear during walking, running, or climbing over varied terrains.46 The results of this trial offer a feasible intervention in the treatment of patellar tendinopathy. Review of studies with 24-week follow- Table 2. LEFS Within Groups at Time Intervals (Mean ± SD, Range) up comparing eccentric squat to other meth-

Group Baseline 4 weeks 8 weeks 12 weeks 24 weeks ods of treatment for patellar tendinopathy 12 n=17 n=17 n=16 n=15 n=12 yielded similar results. Kongsgaard et al reported VISA-P change score of 22 points (p Standard 57.5 ± 12.1 61.5 ± 10.9 65.5 ± 9.8 66.2 ± 10.3 66.8 ± 9 < .01) for unilateral eccentric squat group in (26-74) (42-79) (50-79) (36-78) (55-80) a study involving recreational athletes com- p=0.194 p = 0.007 p=0.002 p=0.008 paring corticosteroid injection, heavy slow n=14 n=13 n=11 n=12 n=8 resistive exercises, and eccentric squats. Bahr et al22 reported an average VISA-P change Treatment 54.8 ± 13 53.6 ±16.7 63.1 ± 13.4 64 ± 14.4 64.4 ± 17.4 score of 29 in both groups (single leg decline (34-73) (27-76) (34-80) (35-80) (34-80) eccentric squats and open tenectomy) with a p=0.775 p = 0.026 p=0.018 p=0.007 study population of participants reportedly 25 Note: p values measured from baseline to respective time, significant at p< 0.05. participating in fitness activities. Thijs et al

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6938_OP_Jan.indd 11 12/17/18 12:55 PM also reported VISA-P change of 19.3 for a lar tendinopathy studies reported exercise than a resistance band, which was provided group performing single leg decline eccentric adherence rates as 66%22 and 72%20; sub- to each participant. The eccentric squat exer- squats (N=30). Each of the respective studies stantially higher than reported in the pres- cise required participants to construct a 25° were generally similar to the present regard- ent study. Reasons for lack of adherence with decline board. Complexity of exercise equip- ing baseline characteristics. log completion or exercise participation is ment may have limited adherence. Addition- In this study, exercise adherence was mea- undetermined, but may be attributed to time ally, patients with chronic conditions have a sured by self-reported exercise logs. Of 31 and complexity. Escolar-Rina et al47 reported tendency to be less adherent to home exercise participants, only 14 returned exercise logs. the most common factor to adherence with programs.48 Both groups had average symp- Standard-of-care group had 5 logs returned home exercise program completion was time tom durations in excess of 6 months. with an average adherence rate of 42.5%. In and complexity of exercises. In the present the treatment group, 9 logs were returned study, exercises provoked symptoms. Despite Limitations with participants reporting 50% adherence extensive education on the desired and neces- Participants were seen weekly for the first with eccentric squat and 62% adherence sary response of pain associated with exercise, 4 weeks and then as needed based upon par- with hip muscle strengthening exercises. some participants may still not have com- ticipant and therapist discretion. This type of With less than half of the participants return- plied due to pain. Hip muscle strengthening schedule precludes frequent feedback which ing exercise logs, true rates of adherence are resulted in greatest exercise adherence. This has been suggested to improve adherence unknown. Comparison of previous patel- exercise required no external equipment other rates.49,50 Our 50% adherence with eccentric squat and 62% adherence with hip muscle strengthening exercises over 12-week training period may have been a limitation for Table 3. VISA-P Within Groups at Time Intervals (Mean ± SD, Range) this study. Patient satisfaction was not measured. Group Baseline 4 weeks 8 weeks 12 weeks 24 weeks Previous research12 has favored heavy slow n=17 n=17 n=16 n=15 n=12 resistive exercise programs with improved Standard 51.7 ± 14.2 60.5 ± 11.9 67.1 ± 15.9 67.3 ± 16.1 70.4 ± 18.8 patient's satisfaction and exercise adherence over a home-based program as described (28-70) (41-85) (44-97) (42-96) (47-100) above. Both programs provide equivocal p=0.059 p = 0.002 p=0.002 p=0.001 results. A common theme reported, while n=14 n=13 n=11 n=12 n=8 not directly measured, was lack of time to Treatment 51.8 ± 13.7 52.7 ±25.2 59.1 ± 19.8 63.8 ± 25.1 72 ± 28 complete prescribed exercise programs due to long work hours. (26-73) (13-96) (26-94) (19-97) (31-100) As this was a pilot study, the investiga- p=0.738 p = 0.393 p=0.105 p=0.002 tors observed that the overall protocol was Note: p values measured from baseline to respective time, significant at p< 0.05

Table 4. Outcome Measures at Time Intervals Between Groups (Mean)

Group Baseline 4 weeks 8 weeks SOC Tx p SOC Tx p SOC Tx p n=17 n=14 n=17 n=13 n=16 n=11

LEFS 57.7 54.8 0.531 61.5 53.6 0.130 65.5 63.1 0.339 VISA-P 51.7 51.8 0.990 60.5 52.7 0.311 67.1 59.1 0.110 VAS 3.9 4.1 0.754 3.7 3.5 0.720 2.5 2.9 0.490

Outcome Measures at Time Intervals Between Groups (Mean) Measure 12 weeks 24 weeks SOC Tx p SOC Tx p n=15 n=12 n=12 n=8 LEFS 66.2 64 0.337 66.8 64.4 0.774 VISA-P 67.3 63.9 0.349 70.4 72 0.840 VAS 2.3 2.9 0.294 2.6 1.9 0.593 Abbreviations: SOC, standard of care: Tx, treatment; LEFS, lower extremity functional scale; VISA-P, Victorian Institute of Sport Assessment – Patella; VAS, visual analog scale Significant at p< 0.05

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6938_OP_Jan.indd 12 12/17/18 12:55 PM feasible but, due to an inherent small sample size, generalizations should be viewed with caution. In the military health care environment, long-term follow-up is threatened, specificallyat 24 weeks, due to personnel relocation or discontinuation of military service. Steps were taken in the intake process to minimize this risk. Additionally, the same therapist conducted all treatments and collected all outcome measures that introduces bias yet allowed consistency in protocol.

Future research Systematic reviews16,51 and expert com- mentaries52,53 highlight the need for investigation of nervous system involvement via central or peripheral sensitization along with cortical reorganization for knee pathology. Figure 3. LEFS scores. Research should move away from standardized protocols and should be based on clinical guidelines that focus on pain control, tendon remodeling, intrinsic and extrinsic factors, and altered neural function. Tendon remodeling exercises should remain a central component of treatment programs while also addressing regional interdependence. Both intrinsic and extrinsic factors such as biomechanical faults, age, co-morbidities, adiposity, training volume, intensity, and environment must be appropriately addressed to restore functional ability and reduce/minimize risk of repeat injury.53 Cook and Purdam1 proposed 3 stages of tendinopathy. Effort should be made to establish reliable and valid assessment techniques that allow for appropriate classifica- tion of each stage. Once each stage can be accurately classified, treatments can be tested for each homogenous subgroup. Figure 4. VISA-P scores.

CONCLUSION Similarly favorable effects were dem- Table 5. VAS for Pain with Activity Within Groups at Time Intervals (Mean ± SD, onstrated in military personnel with patel- Range) lar tendinopathy using either a combined treatment of eccentric squat and hip muscle Group Baseline 4 weeks 8 weeks 12 weeks 24 weeks strengthening or traditional SOC exercises n=17 n=17 n=16 n=15 n=12 (eccentric squat) over a 24 week follow-up. Standard 3.9 ± 1.7 3.7 ± 1.9 2.5 ± 2.2 2.3 ± 1.8 2.6 ± 2 Outcome measures (LEFS, VISA-P, and VAS (1.2-6.9) (0.2-6.8) (0-6.3) (0-5.9) (0-5.3) for pain with activity) improved similarly in both groups over time. Low enrollment p=0.768 p = 0.035 p=0.004 p=0.052 numbers, poor reported exercise adherence, n=14 n=13 n=11 n=12 n=8 lack of soldier-specific task outcome measure, Treatment 4.1 ± 2 3.5 ±2.3 2.9 ± 2.1 2.9 ± 2.2 1.9 ± 1.9 and loss to follow-up likely affected results. (1-7.2) (1-7.8) (0-7.7) (0-6.1) (0-5.3) Overall, both groups improved, suggesting either treatment strategy is likely to result in p=0.265 p = 0.202 p=0.093 p=0.013 improvements when treating an active duty Note: p values measured from baseline to respective time, significant at p< 0.05 military population.

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6938_OP_Jan.indd 13 12/17/18 12:55 PM REFERENCES

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6938_OP_Jan.indd 14 12/17/18 12:55 PM Table 8. Triple Hop Involved Within Groups at Time Intervals (Mean ± SD, Range) chronic patellar tendinopathy have an

Group Baseline 4 weeks 8 weeks 12 weeks 24 weeks altered somatosensory profile? A Quanti- tative Sensory Testing (QST) study. Scand n=17 n=17 n=16 n=15 n=11 J Med Sci Sports. 2013;23(2):149-155. Standard 4.21 ± 0.81 4.29 ± 0.84 4.54 ± 0.85 4.5 ± 0.83 4.33 ± 0.77 doi:10.1111/j.1600-0838.2011.01375.x. (2.62-5.74) (1.86-5.29) (2.38-5.77) (2.59-6.06) (3.1-6) Epub 2011 Sep 13. p=0.875 p = 0.071 p=0.084 p=0.291 18. Cook JL, Rio E, Purdam CR, Dock- ing SI. Revisiting the continuum model n=14 n=13 n=11 n=12 n=6 of tendon pathology: what is its merit Treatment 4.24 ± 0.73 4.39 ± 0.79 4.61 ± 0.89 4.56 ± 0.82 4.69 ± 0.54 in clinical practice and research? Br J (2.61-5.28) (3.02-5.97) (3.22-6.23) (2.83-6.01) (3.91-5.26) Sports Med. 2016;50(19):1187-1191. doi:10.1136/bjsports-2015-095422. p=0.570 p = 0.104 p=0.264 p=0.281 Epub 2016 Apr 28. Note: distance measured in meters, p values measured from baseline to respective time, 19. Larsson ME, Käll I, Nilsson-Helander Significant at p< 0.05 K. Treatment of patellar tendinopathy— a systematic review of randomized controlled trials. Knee Surg Sports Trau- Table 9. Triple Hop Uninvolved Within Groups at Time Intervals (Mean ± SD, matol Arthrosc. 2012;20(8):1632-1646. Range) doi:10.1007/s00167-011-1825-1. Epub 2011 Dec 21. Group Baseline 4 weeks 8 weeks 12 weeks 24 weeks 20. Young MA, Cook JL, Purdam CR, Kiss n=17 n=17 n=16 n=15 n=11 ZS, Alfredson H. Eccentric decline Standard 4.28 ± 0.81 4.34 ± 0.73 4.46 ± 0.76 4.41 ± 0.78 4.29 ± 0.85 squat protocol offers superior results at 12 months compared with traditional (2.83-5.84) (2.51-5.35) (2.54-5.59) (2.68-5.64) (2.99-5.96) eccentric protocol for patellar tendi- p=0.340 p = 0.106 p=0.253 p=0.482 nopathy in volleyball players. Br J Sports n=14 n=13 n=11 n=12 n=6 Med. 2005;39(2):102-105. doi:10.1136/ Treatment 4.33 ± 0.79 4.41 ± 0.72 4.49 ± 0.81 4.52 ± 0.87 4.77 ± 0.31 bjsm.2003.010587. 21. Purdam CR, Jonsson P, Alfredson H, (2.27-5.44) (2.64-5.51) (2.93-5.9) (2.5-6.08) (4.36-5.28) Lorentzon R, Cook JL, Khan KM. A p=0.483 p = 0.395 p=0.702 p=0.540 pilot study of the eccentric decline squat Note: distance measured in meters, p values measured from baseline to respective time, in the management of painful chronic Significant at p< 0.05 patellar tendinopathy. Br J Sports Med. 2004;38(4):395-397. doi:10.1136/ bjsm.2003.000053. 22. Bahr R, Fossan B, Løken S, Engebretsen L. Surgical treatment compared with eccentric training for patellar tendi- neovessels in painful chronic patellar ten- 14. Magnusson SP, Langberg H, Kjaer M. nopathy (Jumper’s Knee). A randomized, dinopathy: a randomized controlled trial. The pathogenesis of tendinopathy: controlled trial. J Bone Joint Surg Am. Am J Sports Med. 2006;34(11):1738- balancing the response to loading. Nat 2006;88(8):1689-1698. doi:10.2106/ 1746. doi:10.1177/0363546506289168. Rev Rheumatol. 2010;6(5):262-268. JBJS.E.01181. Epub 2006 Jul 10. doi:10.1038/nrrheum.2010.43. Epub 23. Jonsson P, Alfredson H. Superior results 12. Kongsgaard M, Kovanen V, Aagaard P, 2010 Mar 23. with eccentric compared to concentric et al. Corticosteroid injections, eccen- 15. Sharma P, Maffulli N. Tendon injury quadriceps training in patients with tric decline squat training and heavy and tendinopathy: healing and repair. J jumper’s knee: a prospective randomised slow resistance training in patellar Bone Joint Surg Am. 2005;87(1):187-202. study. Br J Sports Med. 2005;39(11):847- tendinopathy. Scand J Med Sci Sports. doi:10.2106/JBJS.D.01850. 850. doi:10.1136/bjsm.2005.018630. 2009;19(6):790-802. doi:10.1111/ 16. Plinsinga ML, Brink MS, Vicenzino 24. Frohm A, Halvorsen K, Thorstensson j.1600-0838.2009.00949.x. Epub 2009 B, van Wilgen CP. Evidence of ner- A. A new device for controlled eccentric May 28. vous system sensitization in commonly overloading in training and rehabilitation. 13. McCreesh KM, Riley SJ, Crotty JM. presenting and persistent painful tendi- Eur J Appl Physiol. 2005;94(1-2):168- Neovascularity in patellar tendinopathy nopathies: a systematic review. J Orthop 174. doi:10.1007/s00421-004-1298-8. and the response to eccentric training: a Sports Phys Ther. 2015;45(11):864-875. Epub 2005 Feb 18. case report using Power Doppler ultra- doi:10.2519/jospt.2015.5895. Epub 25. Thijs KM, werverZ J, Backx FJG, et sound. Man Ther. 2013;18(6):602-605. 2015 Sep 21. al. Effectiveness of shockwave treat- doi:10.1016/j.math.2012.09.001. Epub 17. van Wilgen CP, Konopka KH, Keizer D, ment combined with eccentric training 2012 Sep 27. Zwerver J, Dekker R. Do patients with for patellar tendinopathy: a double-

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6938_OP_Jan.indd 15 12/17/18 12:55 PM blinded randomized study. Clin J Sport ized controlled clinical trial with 1-year 2014;48(14):1088. doi:10.1136/bjs- Med. 2017;27(2):89-96. doi:10.1097/ follow-up. J Orthop Sports Phys Ther. ports-2013-093305. Epub 2014 Mar 31. JSM.0000000000000332. 2012;42(10):823-830. doi:10.2519/ 44. Bolgla LA, Earl-Boehm J, Emery C, 26. Scattone Silva R, Nakagawa TH, Ferreira jospt.2012.4184. Epub 2012 Aug 2. Hamstra-Wright K, Ferber R. Compari- AL, Garcia LC, Santos JEM, Serrão FV. 35. Thomeé R. A comprehensive treat- son of hip and knee strength in males Lower limb strength and flexibility in ment approach for patellofemoral pain with and without patellofemoral pain. athletes with and without patellar tendi- syndrome in young women. Phys Ther. Phys Ther Sport. 2015;16(3):215-221. nopathy. Phys Ther Sport. 2016;20:19-25. 1997;77(12):1690-1703. doi:10.1016/j.ptsp.2014.11.001. Epub doi:10.1016/j.ptsp.2015.12.001. Epub 36. 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6938_OP_Jan.indd 16 12/17/18 12:55 PM PHYSICAL THERAPY MANAGEMENT OF CONCUSSION Independent Study Course 28.1

Learning Objectives Editorial Staff 1. Describe the signs, symptoms, biomechanics, and pathophys- Christopher Hughes, PT, PhD, OCS, CSCS—Editor iology of a concussion. Gordon Riddle, PT, DPT, ATC, OCS, SCS, CSCS—Associate Editor 2. Cite key risk factors for sustaining a concussion and indicators Sharon Klinski—Managing Editor leading to prolonged recovery following concussion. 3. Describe common clinical profi les seen following concussion. Topics and Authors 4. Discuss the role of biomarkers in the evaluation and manage- The Basics of Concussion ment of concussion. Anne Mucha, PT, DPT, MS, NCS 5. Understand negative consequences of poor concussion Cara Troutman-Enseki, PT, DPT, OCS, SCS management. 6. Describe important guidelines for return to play following Physical Therapy Evaluation of Concussion sport-related concussion. Anne Mucha, PT, DPT, MS, NCS POSTOPERATIVE7. Discuss the advantages and disadvantages of MANAGEMENTvarious concus- Cara Troutman-Enseki, PT, DPT, OCS, SCS sion prevention strategies. Tim Ryland, PT, EdD(c), MPT, OCS, CBIS 8. Select evidence-based tools and outcomePOSTOPERATIVE measures for MANAGEMENT CHRONIC BACK PAIN clinical evaluation and treatment of concussion. Advanced Concussion Management OF ORTHOPAEDIC9. Apply key examination and assessment methods for cervical/ SURGERIESAnne Mucha, PT, DPT, MS, NCS thoracic spine, vestibular/oculomotor system, and exertionOF ORTHOPAEDICCara Troutman-Enseki, PT, DPT, OCS, SURGERIES SCS following concussion. IndependentTim Ryland, PT, EdD(c), Study MPT, Course OCS, CBISIndependent 27.1 Study Course 27.1 10. Appreciate the role of neurocognitive testing in concussion evaluation and management. Learning Objectives Description Pelvic Rotator 1. Describe anatomy of the hip joint andContinuing how structure can re- EducationThis 6-monograph Credit course covers postoperative management for ompanion Learning Objectives 11. Identify clinical profi les and treatment strategiesDescriptionlate to for pathological each conditions. injuries and pathology of the hip, knee, ankle/foot, cervical/lum- C Fifteen contact hours will be awarded to registrants Cuff Book and 1. Describe anatomy of the hip jointconcussion and how subtype: structure cervical, can re- vestibular, ocular,2.This Describe mood,6-monograph indications mi- for surgical course intervention covers and postoperative select bar spine, management shoulder, and elbow. for Each monograph addresses the surgical procedures of the hip. who successfully completeanatomy the fiand nal biomechanics examination. of the structure, a review of select late to pathological conditions.graine, and cognitive/fatigue. 3.injuries Describe andpostoperative pathology rehabilitation Theof the Orthopaedicintervention hip, knee, tech- Section ankle/foot,or pursues common injuries,cervical/lum- CEU approvaland nonsurgical from and thesurgical management. DVD combo for 12. Describe important indicators for return to activityniques following following hip surgery. following states: Nevada,Emphasis Ohio, Oklahoma,is placed on rehabilitation California, guidelines, precautions and 2. Describe indications for surgical intervention and select 4.bar Know spine, the common shoulder, structures andand pathomechanics elbow. Each involved monographcontraindications addresses to care, and the also expected outcomes. Set just $49.95* concussion. surgical procedures of the hip. anatomyin knee injury. and biomechanicsand Texas. of the Registrants structure, from a other review states of must select apply 5. Describe the physical therapy guidelines, phases, and goals 13. Discuss the role of sleep in concussion management, and to their individual State LicensureTopics and Boards Authors for 3. Describe postoperative rehabilitation intervention tech- or forcommon a patient who injuries, has undergone and knee surgery.nonsurgical and surgicalHip—Keelan management. Enseki, PT, MS, OCS, SCS, ATC, CSCS; employ interventions that can be used to6. modifyUnderstand sleep the etiology of a calcanealapproval fracture, of continuingLisfranc educationDave Kohlrieser, credit. PT, DPT, OCS, SCS, CSCS; Craig Mauro, MD; niques following hip surgery. dysregulation. Emphasisfracture/dislocation, is placed and an Achilleson rehabilitation tendon rupture. guidelines,Michaela precautions Kopka, MD, FRCSC; and Tom Ellis, MD Pelvic Pain & 4. Know the common structures14. and Appreciate pathomechanics the infl uence involved of psychogenic factors7.contraindications in Identify concussion the advantages and to disadvantages care, and of alsosurgical expected fi xa- Kneeoutcomes.—Michael J. Axe, MD; Lynn Synder-Mackler, PT, ScD, tion versus closed treatment for calcanealCourse fractures. content is not intendedFAPTA; Anna for Shovestul use Grieder, PT, DPT, OCS; Jeff Miller, PT, Low Back Pain in knee injury. management. 8. Develop appropriate treatment plansby forparticipants patients who have outside theDPT, scope OCS, SCS; Melissa Dreger, PT, DPT; Michael Palmer, PT, 15. Describe common pharmacologic and non-pharmacologicsustained a calcaneal fracture, Lisfranc fracture/dislocation, DPT, OCS; Tara Jo Manal, PT, DPT, OCS, SCS, FAPTA book only $24.95 5. Describe the physical therapy guidelines, phases, and goals Topicsor an Achilles and tendon rupture.Authorsof their license or regulation.Ankle and Foot—Stephanie Albin, DPT, OCS, FAAOMPT; for a patient who has undergonetreatment knee surgery. options for specifi c symptoms following9. Synthesize concussion. the current evidence comparing conservative Mark Cornwall, PT, PhD, FAPTA; Drew H. VanBoerum, MD Hipcare—Keelan versus early surgeryEnseki, in different PT, MS, subgroups OCS, of patients SCS, ATC, CSCS;Cervical and Lumbar Spine—Paul Reuteman, PT, DPT, with cervical and lumbar spine pain. MHS, OCS, ATC 3 6. Understand the etiology of a calcaneal fracture, Lisfranc Dave Kohlrieser, PT, DPT, OCS, SCS, CSCS; Craig Mauro, MD; Description 10.For Identify Registration the clinical fi ndings that identify and patients Fees,who are Shoulder—Brittany Lynch, PT, DPT, SCS, OCS; 3 Item fracture/dislocation, and anThis Achilles monograph tendon series rupture. provides in-depth coverageMichaela mostfor likelythe toeval-Kopka, benefi t from MD, cervical FRCSC; or lumbar surgicalTom inter-Ellis, MD Heather Christain, PT, DPT, SCS, OCS, CSCS; vention. Christopher L. McCrum, MD; Dharmesh Vyas, MD, PhD Companion Set 7. Identify the advantages anduation disadvantages and treatment of surgicalof concussion fi xa- by a physical11.visitKnee therapist. Screen—Michael andorthopt.org appropriatelyThe J. Axe, manage MD; postoperative Lynn complica- Synder-Mackler,Elbow—Julia PT, L. ScD, Burlette, PT, DPT, OCS; Amy B. Pomrantz, PT, tion versus closed treatmentauthors for calcaneal are recognized fractures. clinical experts in the fi eldFAPTA; oftions concussion for presentedAnna Shovestul pathologies. Grieder, PT, DPT, OCS;DPT, Jeff OCS, ATC; Miller, Chris A. PT, Sebelski, PT, PhD, OCS, CSCS; Justin M. 12. Develop an evidence-based rehabilitation program for pa- Lantz, PT, DPT, OCS, FAAOMPT; John M. Itamura, MD just $69.95 8. Develop appropriate treatmentmanagement. plans for The patients basic pathophysiology who have underlyingDPT,tients concussion OCS, who have SCS; undergone Melissa different Dreger, cervical and PT, lumbar DPT; Michael Palmer, PT, is presented and then coupled with essential and advancedsurgeries. exam- Continuing Education Credit sustained a calcaneal fracture, Lisfranc fracture/dislocation, 13.AdditionalDPT, Integrate OCS; biomechanics Tara Jo andQuestions– Manal, pathomechanics PT, DPT, of the shoul-OCS, SCS, FAPTA ination techniques. Special emphasis is placed on examination of Thirty contact hours will be awarded to registrants or an Achilles tendon rupture. Ankleder to evaluationand Foot and treatment.—Stephanie Albin, DPT, OCS,who FAAOMPT; successfully complete the fi nal examination. Order at: www.phoenixcore.com the cervical and thoracic spine as part of concussion14.Call Implement assessment toll evidence-based free nonoperative treatment strate- The Orthopaedic Section pursues CEU approval 9. Synthesize the current evidence comparing conservative gies for shoulder pathology. and treatment. Mark Cornwall, PT, PhD, FAPTA; Drew H. VanBoerum,from the following MD states: Nevada, Ohio, care versus early surgery in different subgroups of patients 15.800/444-3982 Describe evidence-based rehabilitation guidelines follow- Oklahoma, California, and Texas. Registrants or call 1-800-549-8371 Cervicaling shoulder and surgery. Lumbar Spine—Paul Reuteman,from PT, other DPT, states must apply to their with cervical and lumbar spine pain. 16.MHS, Understand OCS, the ATC anatomy and biomechanics of the elbow individual State Licensure Boards for Also check out our Educational Webinars: Chronic Pain, For Registration and Fees, visit orthoptlearn.orgcomplex and how it relates to surgical interventions, tissue approval of continuing 10. Identify the clinical fi ndings that identify patients who are Shoulderhealing, and—Brittany treatment. Lynch, PT, DPT, SCS, OCS;education credit. Pelvic Rotator Cuff and Beyond Kegels. Visit our website Additional Questions—Call toll free 800/444-398217. Understand postoperative guidelines and treatment pro- most likely to benefi t from cervical or lumbar surgical inter- Heathergression for Christain, the elbow complex. PT, DPT, SCS, OCS, CSCS;Course content is not vention. 18.Christopher Apply appropriate L. patient-reported McCrum, outcomeMD; Dharmesh measures for Vyas,intended MD, for PhD use by for more information and times. select surgical procedures of the hip, knee, ankle/foot, spine, participants outside 11. Screen and appropriately manage postoperative complica- Elbowshoulder,—Julia and elbow. L. Burlette, PT, DPT, OCS; Amy theB. scopePomrantz, of their PT, license or tions for presented pathologies. EditorialDPT, OCS, Staff ATC; Chris A. Sebelski, PT, PhD, OCS,regulation. CSCS; Justin M. 12. Develop an evidence-based rehabilitation program for pa- ChristopherLantz, PT, Hughes, DPT, PT, PhD, OCS, OCS, CSCS—EditorFAAOMPT; John M. Itamura, MD Gordon Riddle, PT, DPT, ATC, OCS, SCS, CSCS—Associate Editor tients who have undergone different cervical and lumbar OrthopaedicSharon Klinski—Managing Practice Editorvolume 31 / number 1 / 2019 17 surgeries. ForContinuing Registration and Fees, Education visit orthoptlearn.org Credit Additional Questions—Call toll free 800/444-3982 13. Integrate biomechanics and pathomechanics of the shoul- Thirty contact hours will be awarded to registrants der to evaluation and treatment. who successfully complete the fi nal examination. 14. Implement evidence-based nonoperative treatment strate- 6938_OP_Jan.inddThe Orthopaedic 17 Section pursues CEU approval 12/17/18 12:55 PM gies for shoulder pathology. from the following states: Nevada, Ohio, 15. Describe evidence-based rehabilitation guidelines follow- Oklahoma, California, and Texas. Registrants ing shoulder surgery. from other states must apply to their 16. Understand the anatomy and biomechanics of the elbow individual State Licensure Boards for complex and how it relates to surgical interventions, tissue approval of continuing healing, and treatment. education credit. 17. Understand postoperative guidelines and treatment progression for the elbow complex. Course content is not 18. Apply appropriate patient-reported outcome measures for intended for use by select surgical procedures of the hip, knee, ankle/foot, spine, participants outside shoulder, and elbow. the scope of their license or Editorial Staff regulation. Christopher Hughes, PT, PhD, OCS, CSCS—Editor Gordon Riddle, PT, DPT, ATC, OCS, SCS, CSCS—Associate Editor Sharon Klinski—Managing Editor For Registration and Fees, visit orthoptlearn.org Additional Questions—Call toll free 800/444-3982 Manual Therapy and Exercise Robert Boyles, PT, DSc, OCS, FAAOMPT1 Andrew Didricksen, SPT1 in Treatment of a Patient with Justin Higa, SPT1 Cervical Radiculopathy Daniel Kobayashi, SPT1

1University of Puget Sound, Tacoma, WA

Background and Purpose: Cervical positive results with thoracic manipulation meta-analysis and systematic review com- radiculopathy (CR) most commonly origi- techniques when treating CR. In the design pared cervical manipulative techniques and nates from space occupying lesions. The of these studies, researchers used a multi- traction in immediate effects on pain mea- purpose of this protocol is to observe the modal approach to treat research subjects. A sured via the Visual Analog Scale found that short-term effects of specific manual therapy study by Cleland et al1 found that 91% of the manipulative techniques resulted in greater and exercise interventions for the thoracic patients classified their level of improvement decreases in pain,9,10 thus supporting the pro- and cervical spine of patients with CR. Meth- as at least “quite a bit better” (+5) on the posed protocol for the study. ods: This protocol included a single subject global rating of change (GROC) scale at dis- It was hypothesized that the use of these pretest-posttest design to determine the charge. Using the Patient Specific Functional specific manual therapy techniques will have short-term effects of thoracic manipulation, Scale and the Neck Disability Index (NDI), a positive effect on CR measured by reduced cervical rotation mobilization, and exercise over 90% of patients demonstrated a clini- levels of pain, disability, and an improvement in a patient with CR. Clinical Relevance: cally meaningful improvement in pain and in ROM. Therefore, the purpose of this case Establishing a specific intervention protocol disability, which continued to persist at a 6 study was to observe the short-term effects of for the treatment of CR will enable clinicians month follow-up. A study by Waldrop2 mea- specific manual therapy techniques directed to use well-defined techniques rather than sured manual therapy treatment outcomes to the thoracic and cervical spine for a patient general multi-modal approaches evident in using Northwick Park Neck Questionnaire with CR. much of the existing literature. Conclusion: demonstrating a reduction of neck pain and We were unable to draw statistically mean- disability that ranged from 13% to 88%. METHODS ingful conclusions about our protocol due Due to the fact that thoracic manipulation Inclusion/Exclusion with Medical to only one subject qualifying for inclusion has previously established positive results in Screening Form in this study. However, this subject showed decreasing neck pain, inclusion in a compre- Participants 18 to 60 years of age, and a clinically meaningful change on the Neck hensive rehabilitation program may be justi- who tested positive for at least 3 out of the Disability Index and Numeric Pain Rating fied.5,6 The Journal of Orthopaedic and Sports 4 test item cluster as reported in the Wainner Scale outcome measures suggesting that Physical Therapy 2017 update to clinical prac- et al clinical prediction rule (CPR) for diag- further investigation using this protocol is tice guidelines included thoracic manipula- nosis of CR were recruited.11 The test items warranted. tion in this patient population with a “B” include: (1) a positive Spurling Test A, (2) a level of recommendation.7 However, specific positive cervical spine distraction test, (3) an Key Words: physical therapy, thoracic protocols have yet to be established for the ipsilateral active cervical spine rotation less manipulation use of these interventions strategies. than 60° towards the symptomatic side, and (4) an Upper Limb Tension Test A for median INTRODUCTION SIGNIFICANCE AND PURPOSE nerve bias. With 3 out of the 4 items present, Cervical radiculopathy (CR) most com- The protocol proposed in this study is this clinical prediction rule has a specificity monly originates from a cervical disc her- designed to incorporate the available evi- of 94%, and a positive likelihood ratio of niation and/or osteophytosis.1 These space dence for treating CR with a novel approach 6.1, making it a useful tool for the diagnosis occupying lesions alter sensory and nocicep- to include unilateral rotation cervical mobi- of CR.5 Exclusion criteria includes less than tive signaling near the nerve root resulting in lization (URCM) in addition to thoracic 3 positive tests on the CPR, two positive radicular pain.1,2 Although present-practice manipulation techniques directed at the neurologic signs or symptoms suggestive of patterns in treating patients with CR incor- upper thoracic spine and cervicothoracic serious neurological pathology, hypermobil- porate the application of a combination of junction. Langevin et al found that there ity of the thoracic spine, osteoporosis, preg- interventions, this study is interested in the was no statistically significant difference nancy, vertebrobasilar insufficiency, trauma, short-term effects of 3 specific manual ther- in manual therapy techniques designed to and previous surgical spine interventions as apy techniques. increase the diameter of the intervertebral determined through the questionnaire.2,5 Prior to the last two decades, there was foramen (IVF) and manual therapy tech- The study was approved by the University of limited evidence for the use of thoracic spine niques without that specific goal.8 However, Puget Sound’s Internal Review Board. manipulation on patients with CR. In 1998, more research is needed to determine the Norlander and his associates found a link veracity of those findings and this protocol OUTCOME MEASURES between mobility in the thoracic spine and will include the URCM technique since it The NDI for neck disability assessment neck and shoulder pain.3 Neck pain, along has a biomechanical basis in increasing the and the Numeric Pain Rating Scale (NPRS) with decreased cervical range of motion IVF diameter to reduce nerve root irritation. for both, the neck and the arm. Active ROM (ROM), are typical symptoms in patients Some evidence points to the use of cer- for cervical spine flexion, extension, and with CR.4 Recent studies have published vical traction to treat CR however a recent lateral flexion were measured using an incli-

18 Orthopaedic Practice volume 31 / number 1 / 2019

6938_OP_Jan.indd 18 12/17/18 12:55 PM nometer and cervical rotation using a goni- lished MDC or MCID thresholds for the manual therapy, traction, exercise, and/or ometer to identify baseline level of ROM. NDI, NPRS for the neck, and GROC.16-18 heat and cold, rendering it difficult to determine what specific interventions led to a Intervention Description DISCUSSION patient’s improvement.20 The treatment consists of high veloc- Due to the single subject nature of this In order to develop a definitive treatment ity low amplitude thoracic spine thrust study, there are many limitations. First, no progression for CR it is important to estab- manipulations (TSTM) performed on the cause-and-effect can be determined with lish the most efficacious treatment option. mid-thoracic spine and cervicothoracic junc- a single subject. Additionally, it cannot be During the development of the treatment tion as described by Boyles and colleagues13 generalized for the patient population with protocol, the authors reviewed a multitude of and a lower amplitude non-thrust unilateral CR, as there is an obvious lack of a control studies that showed the efficacy of thoracic rotation cervical mobilizations (URCM) group with no blinding or randomization. mobilizations on patients with various types as described by Maitland14 (Figure 1). If a With these limitations in mind, the authors of neck pain and found improvements in cavitation is achieved during the first TSTM feel it is important to report the findings and pain, ROM, and disability.20-24 The decision attempt, the treating therapist proceeds to hopefully trigger further studies with larger to incorporate thoracic manipulation was the next segment. If no cavitation is achieved, sample sizes, and possibly a randomized con- based upon regional interdependence.13,25 the patient is repositioned and the TSTM trolled trial. Previous research has shown that there is sig- intervention is repeated for a maximum of The subject did not meet MDC aluesv for nificant movement in the thoracic spine with two attempts. The grades of the URCM will the NPRS in either neck or arm pain. How- unilateral and bilateral arm elevation, leading range from grade 1 to grade 4 depending on ever, the MCID has been shown to be less researchers to conclude that impaired cervi- the individual patient. The manual therapy than the MDC for NPRS arm pain and this cothoracic mobility may be an intrinsic cause treatments are administered in the follow- subject did meet the cutoff score of 2 points of shoulder pain.26 Previous studies have ing order: thoracic manipulations, cervical to show clinically important change.15,16 The demonstrated that the anterior-posterior tho- rotational mobilization, followed by an exer- authors think that the reduction in the sub- racic spine manipulation, and upper thoracic cise program of cervical active ROM, chin ject’s arm pain could be attributed to central- spine distraction manipulation were most tucks, self-cervical mobilizations, and barrel ization, which may be an important clinical effective.2,22,26,27 In regards to mobilizations hug stretches with rotational holds (Figure step in addressing CR. The small change in of the cervical spine a 2011 systematic review 2) that continue at home as well. The NDI the subject's reported scores in the NDI, found that “gentle mobilizations of the cer- and NRPS are completed immediately after NPRS neck, and GROC could be attributed vical spine” were among the most frequent treatment. The subjects return 48 hours after to the initial low disability level as these out- treatments provided though the actual treat- initial treatment for follow-up. At that time, come measures are less sensitive in capturing ments and parameters were not described.22 they will complete the NDI, NPRS, and change when disability levels are low.17 Therefore, our protocol adopted the use of GROC, for both cervical and arm pain. Cer- For active ROM, the subject saw an the mid-thoracic spine thrust manipulation, vical active ROM is also measured following increase in left cervical rotation of 10° pos- cervicothoracic junction thrust manipula- the data collection, the subject’s participation tintervention (Table 1) at 48 hours reas- tion, and unilateral rotation cervical mobi- in the study is complete. sessment. While his initial increase in right lizations for the manual therapy portion of cervical rotation may be explained by the our protocol. Patient Outcome acute effects of the local rotation mobiliza- The primary aim of the home exercise In our study, of the 5 patients screened tions that were performed in right cervical program was to restore normal flexibility, for CR, only 1 subject met the necessary cri- rotation, the increase in left rotation fol- stability, and postural mechanics through the teria for cervical radiculopathy reported by lowing 48 hours may be due to the cumu- strengthening and conditioning of the cervi- Wainner et al.11 The subject was a 22-year- lative effect of our interventions indicating cal stabilizers and increase the limitations of old male presenting with left sided arm pain a desensitization of the affected nerve root. cervical spine movement through flexibility provoked by spinous process and ipsilateral Ipsilateral rotation is thought to decrease IVF exercises. Postural correction is frequently a articular pillar palpation of the C7 vertebrae. cross sectional area while being an irritant to part of treatment in order to decrease abnor- He was also positive on all 4 tests included in patients affected by CR. In contrast, rotation mal mechanical stressors on the cervical the CPR for CR. away from the affected limb will theoretically spine.2 To address this, our treatment pro- Immediately following the treatment increase IVF cross sectional area, which will tocol included chin tuck exercise, barrel hug his ROM improved exceeding the minimal in turn decrease pressure on the nerve root. stretch, cervical self-mobilization, and active detectable change (MDC) for cervical right This effect coupled with the upstream effects ROM exercises. These exercises sans the barrel rotation. Forty-eight hours after treatment of the thoracic and CT junction manipu- hug stretch appear frequently throughout the patient also showed increased ROM in left lations may have realigned the facets to literature in improving outcomes in patients rotation and further demonstrated improve- improve the cervical rotation. with neck pain and shoulder pain.2,20,22,26-28 ments in all outcome measures aside from The effectiveness of a specific treatment cervical extension ROM (Tables 1 and 2). protocol for short-term improvement in CONCLUSION In addition, the 2-point improvement on patients with CR had not been investigated. Based on the results of this case report, the the NPRS arm scale reported by the subject Therapeutic interventions in previous stud- authors believe that this treatment protocol immediately postintervention and at the ies were applied according to therapist pref- or elements warrant consideration as part of 48-hour follow-up met the established mini- erence.13,19 Much of the prior research on decision-making and treatment for patients mal clinically important difference (MCID) treatment for cervical radiculopathy used a with CR. The authors believe that the proto- threshold.15 This subject did not reach estab- multi-modal approach of immobilization, col can be safely implemented and does not

Orthopaedic Practice volume 31 / number 1 / 2019 19

6938_OP_Jan.indd 19 12/17/18 12:55 PM Figure 1. Manual Physical Therapy Techniques

Technique Description of Technique Illustration Mid-thoracic spine - Start with the researcher standing behind the subject who will be thrust sitting at the edge of the treatment table. manipulation - Next, the region of the spine to be thrust is placed against the researcher’s chest. - The researcher then reaches around the subject and grasps the subject’s elbows, with knees slightly flexed. - The subject is told to relax and take a deep breath. - After exhalation, the researcher will apply pressure to the subject’s upper body through the subject’s arms. - At the same time, the researcher extends knees to lift the subject’s body slightly up and over the fulcrum established by the chest making a J-stroke with the subject’s arms.12

Cervicothoracic - Start with the subject sitting with fingers interlocked behind the lower junction thrust cervical spine, and the researcher standing behind with his shoulders manipulation level with the subject’s shoulders. - The researcher then threads the arms through the subject’s arms so that the researcher’s hands are on top of the subject’s hands at the CT junction. - The subject is then told to move their hands as low as they can and to relax their arms. - Care is taken not to hyperextend the patient's shoulder, but rather use the researcher’s forearms in a compressive manner anterior to the shoulder. - The researcher then tilts the subject back so that the cervical spine is oriented perpendicular to the floor. - After the subject exhales (on her natural breathing relaxation), the researcher extends his legs and lumbar spine to apply a high velocity low amplitude force against gravity to distract.12

Unilateral rotation - Starting with the subject lying supine with her head and neck cervical extended beyond the end of the treatment table and supported by the mobilization therapist. - The head will be rotated contralaterally from the painful side. The subject’s symptoms determine the grade and range of mobilization used in treatment. The therapist cradles the patient’s head and neck with the fingers spread out over the ipsilateral side of the occiput and neck. - The patient’s chin is supported with the other hand. The subject’s head may be raised and lowered to place the joint being treated between its flexion and extension limits. - The therapist turns the head in the direction it is placed with a simultaneous action of both hands (ie, if the head is rotated to the left for the starting position it will be turned further left for the mobilization). - It is important that the contralateral hand generate the same amount of motion of the occiput as the left hand produces with the chin. This maneuver is produced purely by the researcher’s arm movements.13

Figure 1. Manual physical therapy techniques.

20 Orthopaedic Practice volume 31 / number 1 / 2019

6938_OP_Jan.indd 20 12/17/18 12:55 PM Exercise Description of Exercise Picture

Chin tuck -Start with the patient seated upright. -Next place two fingers on the chin. -The patient then uses the two fingers -to gently push the chin straight backward creating a skin roll along the jaw line.

Repeat ___ times Perform ___ times daily

1 2

Barrel hug stretch -Start with the patient seated upright. -The patient will eachr out in front -of the body, imitating the motion of hugging a barrel. -Then the patient will otater from one -side to the other and push the chest away from their outstretched hands.

Repeat ___ times Perform ___ times daily 1 2 3

Figure 2. Home exercise program.

require a significant amount of treatment time.25,29 Due to the limitations previously mentioned, the authors recommend further cervico-thoracic spine. Scand J Rehabil 7. Blanpied PR, Gross AR, Elliott JM, et study using a more rigorous research design. Med. 1998;30(4):243-251. al. Neck Pain: Revision 2017. J Orthop 4. van Giijn J, Reiners K, Toyka KV, Sports Phys Ther. 2017;47(7):A1-A83. REFERENCES Braakman R. Management of cer- doi: 10.2519/jospt.2017.0302. vical radiculopathy. Eur Neurol. 8. Langevin P, Desmeules F, Lamothe M, 1. Cleland JA, Whitman JM, Fritz JM, 1995;35(6):309-320. Robitaille S, Roy JS. Comparison of 2 Palmer JA. Manual physical therapy, cer- 5. Cleland JA, Childs JD, McRae M, manual therapy and exercise protocols vical traction, and strengthening exercises Palmer JA, Stowell T. Immediate effects for Cervical radiculopathy: a randomized in patients with cervical radiculopathy: of thoracic manipulation in patients with clinical trial evaluating short-term effects. a case series. J Orthop Sports Phys Ther. neck pain: a randomized clinical trial. J Orthop Sports Phys Ther. 2015:45(1):4- 2005;35(12):802-811. Man Ther. 2005;10(2):127-135. 17. doi: 10.2519/jospt.2015.5211. 2. Waldrop MA. Diagnosis and treatment 6. Cleland JA, Glynn P, Whitman JM, 9. Zhu L, Wei X, Wang S. Does cervi- of cervical radiculopathy using a clinical Eberhart SL, MacDonald C, Childs cal spine manipulation reduce pain prediction rule and a multimodal inter- JD. Short-term effects of thrust versus in people with degenerative cervical vention approach: a case series. J Orthop nonthrust mobilization/manipulation radiculopathy? A systematic review of Sports Phys Ther. 2006;36(3):152-159. directed at the thoracic spine in patients the evidence, and a meta-analysis. Clin 3. Norlander S, Nordgren B. Clinical with neck pain: a randomized clinical Rehabil. 2016;30(2):145-155. doi: symptoms related to musculoskeletal trial. Phys Ther. 2007;87(4):431-440. 10.1177/0269215515570382. Epub neck-shoulder pain and mobility in the 2015 Feb 13.

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6938_OP_Jan.indd 21 12/17/18 12:55 PM Table 1. Cervical Range of Motion Data Cervical ROM Cervical Cervical Right Left Left Right 18. Cleland JA, Fritz JM, Whitman JM, Flexion Extension Sidebend Sidebend Rotation Rotation Palmer JA. The reliability and construct validity of the Neck Disability Active ROM 32 61 42 40 52 49 Baseline Index and patient specific functional scale in patients with cervical radicu- Active ROM 37 60 45 42 54 60 lopathy. Spine (Phila Pa 1976). Postintervention 2006;31(5):598-602. Active ROM 30 52 46 40 62 52 19. Wainner RS, Gill H. Diagnosis and 2 Day Follow-up nonoperative management of cervical Change at -2 -9 4 0 10 3 radiculopathy. J Orthop Sports Phys Ther. Follow-up 2000;30(12):728-744. Abbreviation: ROM, range of motion 20. Walker MJ, Boyles RE, Young BA, et al. The effectiveness of manual physical therapy and exercise for Table 2. Questionnaire Outcome Measures mechanical neck pain: a randomized clinical trial. Spine (Phila Pa 1976). Outcome Measures NDI NPRS Arm NPRS Neck GROC 2008;33(22):2371-2378. doi: 10.1097/ Baseline 13 5 3 N/A BRS.0b013e318183391e. Postintervention N/A 3 2 N/A 21. Strunce JB, Walker MJ, Boyles RE, 2 Day Follow-up 8 3 2 1 Young BA. The immediate effects of thoracic spine and rib manipulation Change at Follow-up 5 2 1 1 on subjects with primary complaints Abbreviations: NDI, Neck Disability Index; NPRS, Numeric Pain Rating Scale; of shoulder pain. J Man Manip Ther. GROC, Global Rating of Change 2009;17(4):230-236. 22. Boyles R, Toy P, Mellon J Jr, Hayes M, Hammer B. Effectiveness of manual physical therapy in the treatment of cervical radiculopathy: a systematic review. J Man Manip 10. Fritz JM, Thackeray A, Brennan GP, Man Ther. 2009;14(4):375-380. doi: Ther. 2011;19(3):135-142. doi: Childs JD. Exercise only, exercise with 10.1016/j.math.2008.05.005. Epub 10.1179/2042618611Y.0000000011. mechanical traction, or exercise with 2008 Aug 15. 23. McGregor C, Boyles R, Murahashi over-door traction for patients with 14. Maitland GD, Hengeveld E, Banks K, L, Sena T, Yarnall R. The immedi- cervical radiculopathy, with or without English K. Maitland’s Vertebral Manipula- ate effects of thoracic transverse consideration of status on a previously tion. 7th ed. Philadelphia, PA: Elsevier mobilization in patients with the described subgrouping rule: a random- Butterworth-Heinemann; 2005. primary complaint of mechani- ized clinical trial. J Orthop Sports Phys 15. Michener LA, Snyder AR, Leggin BG. cal neck pain: a pilot study. J Man Ther. 2014;44(2):45-57. doi: 10.2519/ Responsiveness of the numeric pain Manip Ther. 2014;22(4):191-198. doi: jospt.2014.5065. Epub 2014 Jan 9. rating scale in patients with shoulder pain 10.1179/2042618614Y.0000000073. 11. Wainner RS, Fritz JM, Irrgang JJ, and the effect of surgical status. J Sport 24. Chu J, Allen DD, Pawlowsky S, Boninger ML, Delitto A, Allison S. Rehabil. 2011;20(1):115-128. Smoot B. Peripheral response to Reliability and diagnostic accuracy of 16. Cleland JA, Childs JD, Whitman JM. cervical or thoracic spinal manual the clinical examination and patient Psychometric properties of the Neck therapy: an evidence-based review self-report measures for cervical Disability Index and Numeric Pain with meta analysis. J Man Manip radiculopathy. Spine (Phila Pa 1976). Rating Scale in patients with mechani- Ther. 2014;22(4):220-229 doi: 2003;28(1):52-62. cal neck pain. Arch Phys Med Rehabil. 10.1179/2042618613Y.0000000062. 12. Sarfraznawaz S, Manhas A, Parekh K. 2008;89(1):69-74. doi: 10.1016/j. 25. Colloca CJ, Pickar JG, Slosberg M. The effect of the upper limb tension test apmr.2007.08.126. Special focus on spinal manipulation. J in the management of ROM limitation 17. Young IA, Cleland JA, Michener LA, Electromyogr Kinesiol. 2012;22(5):629- and pain in cervical radiculopathy. Int Brown C. Reliability, construct validity, 631. doi: 10.1016/j.jelekin.2012.08.009. J Physiother Res. 2015;3(3):1065-1067. and responsiveness of the neck disability 26. Mintken PE, Cleland JA, Carpenter doi: 10.1695/ijpr.2015.138. index, patient-specific functional scale, KJ, Bieniek ML, Keirns M, Whitman 13. Boyles RE, Ritland BM, Miracle BM, and numeric pain rating scale in patients JM. Some factors predict successful et al. The short-term effects of thoracic with cervical radiculopathy. Am J Phys short-term outcomes in individuals with spine thrust manipulation on patients Med Rehabil. 2010;89(10):831-839. doi: shoulder pain receiving cervicothoracic with shoulder impingement syndrome. 10.1097/PHM.0b013e3181ec98e6. manipulation: a single-arm trial. Phys

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6938_OP_Jan.indd 22 12/17/18 12:55 PM Ther. 2010;90(1):26-42. doi: 10.2522/ ptj.20090095. Epub 2009 Dec 3. 27. Cleland JA, Mintken PE, Carpenter K, 䔀渀最椀渀攀攀爀攀搀爀攀猀椀猀琀愀渀挀攀琀漀漀氀猀爀攀焀甀攀猀琀攀搀戀礀 et al. Examination of a clinical predic- 瀀栀礀猀椀挀愀氀琀栀攀爀愀瀀椀猀琀猀愀渀搀琀栀攀椀爀瀀愀琀椀攀渀琀猀⸀ tion rule to identify patients with neck pain likely to benefit from thoracic spine thrust manipulation and a general cervical range of motion exercise: multi-center randomized clinical trial. Phys Ther. 2010;90(9):1239-1250. doi: 10.2522/ 圀愀氀氀䴀漀甀渀琀䬀椀琀 ptj.20100123. Epub 2010 Jul 15. 䴀䄀圀匀䬀䤀吀 28. Cleland JA, Childs JD, Fritz JM, Whit- ∠ 吀栀攀愀搀樀甀猀琀愀戀氀攀 man JM, Eberhart SL. Development of a 搀攀猀椀最渀愀氀氀漀眀猀昀漀爀 clinical prediction rule for guiding treat- 甀瀀瀀攀爀愀渀搀氀漀眀攀爀 ment of a subgroup of patients with neck 攀砀琀爀攀洀椀琀礀甀猀攀 pain: use of thoracic spine manipulation, ∠ 䔀砀瀀愀渀搀礀漀甀爀欀椀琀眀椀琀栀䴀攀搀椀䌀漀爀搀稀글 exercise, and patient education. Phys 愀挀挀攀猀猀漀爀椀攀猀 Ther. 2007;87(1):9-23. ∠ 䜀爀攀愀琀䜀昀漀爀栀漀洀攀 29. Di Fabio RP. Manipulation of the cervi- 愀猀眀攀氀氀愀猀挀氀椀渀椀挀 cal spine: risks and benefits. Phys Ther. 甀猀攀 1999;79(1):50-65.

匀䄀嘀䔀㈀ ─ 伀䘀䘀夀伀唀刀一䔀堀吀伀刀䐀䔀刀唀匀䔀倀刀伀䴀伀䌀伀䐀䔀㨀㈀倀吀㄀㠀㠀 ⸀㠀㘀㘀⸀㘀㘀㈀㄀簀洀攀搀椀挀漀爀搀稀⸀挀漀洀

A SNEAK PEEK AT THE NEW GUIDELINES PUBLISHING SOON CSM 2019 Programming:

Clinical Practice Guidelines: Shoulder Stability 2019 & Movement Coordination Deficits A. Seitz, T. Uhl, E. Hegedus, L. Michener, K. Matsel NEXT Conference & Exposition June 12-15, 2019 PT Clinical Practice Guideline: Chicago, IL Management Following a Concussive Event C. Quatman-Yates, K. McCulloch, A. Giordano, National Student Conclave K. Kumagai Shimamura, B. Alsalaheen, R. Landel, October 31-November 2, 2019 T. Hanke Albuquerque, NM Physical Therapy Management of Older Adults 2020 with Hip Fracture C. McDonough, M. Kristensen, J. Overgaard, CSM: February 12-15, 2020 M. Harris-Hayes, K. Mangione, T. Herring Denver, CO 2021 CSM: February 24-27, 2021 Orlando, FL

Orthopaedic Practice volume 31 / number 1 / 2019 23

6938_OP_Jan.indd 23 12/17/18 12:55 PM Manual Therapy Application in the Douglas Steele, PT, PA-C, DHS, DPT1 Management of Baastrup’s Disease: Mark Kosier, PT, DPT, FAAOMT, RCMT2 A Case Report

1Assistant Professor, University of Saint Augustine for Health Sciences, St. Augustine, FL 2Clinician, Premier Physical Therapy, Jacksonville, FL

ABSTRACT trup concluded that when exerted through consistent operational definition of Baas- Background and Purpose: Baastrup’s the small contact areas of abutting spinous trup’s is needed to more precisely determine disease has been described as degenerative processes these forces produced lesions in the the incidence and prevalence of this disease. bony and soft tissue changes caused by abut- soft interspinous tissues, resulting in osteo- Historically, intervention for Baastrup’s ment of adjacent spinous processes. Back pain arthritic changes that caused further bone disease has included partial and total resec- associated with Baastrup’s disease has been abutment, inflammation of interspinous tis- tion of the involved spinous processes and treated primarily with surgery and injection sues and central low back pain. Albee’s autoplastic bone graft operation.14,15 therapy. This report presents results and clini- Kwong et al3 noted that since Baastrup’s Surgical outcomes have been mixed with cal reasoning associated with treatment of a early work there has been controversy as to findings cited as complete relief, partial relief, patient with Baastrup’s disease using manual whether the degenerative changes Baastrup and no relief of back pain.8,14,15 It has been physical therapy. Methods: A 62-year-old described are clinically significant4-7 or part purported that adjuvant degenerative spine male with clinical and radiographic evi- of expected changes occurring with age and changes other than those caused by Baas- dence of Baastrup’s was treated with manual not a source of back pain.3,8 However, the trup’s disease were likely responsible for per- physical therapy to correct segmental lumbar preponderance of evidence from anatomic sistent, postsurgical symptomology.8,14 position and arthrokinematic dysfunction. studies,9,10 advanced imaging,11,12 and cases of Less invasive interventions than surgery Findings: Comparison of pre and post inter- successful intervention including young ath- that target likely pain generators in Baas- vention radiographs demonstrated increased letes7,13,14 support the notion that Baastrup’s trup’s disease have been used more recently. interspinous space that corresponded to disease is a disorder of clinical significance Okada et al13 prospectively examined the complete resolution of back pain at week 5 of with a number of potential pain generators short- and long-term effects of interspinous treatment. Clinical Relevance: This report in the interspinous region. ligament injections using local anesthetics exhibits effective treatment of back pain in a The epidemiology of Baastrup’s syn- and steroids for the treatment of back pain in patient with Baastrup’s disease using manual drome is difficult to ascertain. This is due 17 patients with Baastrup’s disease. Postinjec- physical therapy. Conclusion: Further in part to lack of inclusion of this syndrome tion, 4 patients reported 60% to 79% relief, research is needed to determine if there is a in the work-up of back pain, nearly ubiqui- 9 reported 80% to 99% relief, and 4 patients subset of patients with Baastrup’s disease that tous degenerative spine changes consistent reported 100% relief. With long-term fol- can benefit from manual therapy. with Baastrup’s in patients over 65 years of low-up (1.4 years), 15 patients indicated that age, and adjuvant, concurrent spine pathol- the treatment met their expectations and 2 Key Words: Kissing Spine Syndrome, ogy that has a similar clinical presentation.4,8 indicated limited improvement but a willing- segmental dysfunction, back pain, Kwong et al3 found a systematic increase in ness to undergo the same treatment for the rehabilitation the number of cases of Baastrup’s disease with same outcome. Lamer et al4 described the age, when using the description, as evidence treatment of 3 patients with low back pain INTRODUCTION of close approximation and contact between contextual to Baastrup’s disease with fluo- Baastrup’s disease, also described as Kiss- apposing spinous processes and sclerosis of roscopy guided interspinous injections of 2 ing Spine Syndrome, is a spine disorder named the superior and inferior portions of adjacent – 3 mL of 0.25% bupivacaine and 3 mg of after Christian Ingerslev Baastrup, a Danish processes on computed tomography. Maes betamethasone. Two patients experienced radiologist (1855-1950).1 This disorder was et al12 performed a retrospective analysis of long-term relief. One patient who had severe described by Baastrup in 1933 as abutment of 539 consecutive patients undergoing rou- osseous degeneration and cystic changes had the posterior aspect of adjacent spinous pro- tine lumbar spine MRI for back pain or leg only temporary relief but had complete relief cesses due to spinous process shape, degree pain. Using the diagnostic criteria described with a subsequent resection of the involved of lumbar lordosis and degenerative changes as, the presence of interspinous bursitis, they spinous processes. Baastrup’s disease is more resulting in decreased interspinous distance.2 found Baastrup’s disease present in 8.2% or prevalent in an older population, however, Additionally, Baastrup purported that verte- 44 of the 539 patients studied. Similar to the DePalma et al7 reported successful treat- brae act as a lever, the axis of which, in the results of the study by Kwong et al,3 the study ment of L2-3 interspinous bursitis related to frontal plane, lies posterior to the middle of by Maes et al12 also demonstrated an associa- Baastrup’s disease in a 18-year-old, female, the vertebra making the spinous processes tion of increased incidence of Baastrup’s with collegiate basketball player. The patient the short arm of the lever. He reasoned that increasing age. Correlation to advancing age underwent two interspinous bursa injections this short lever was able to drive the spinous notwithstanding, Baastrup’s disease has also with 1 cc of betamethasone and 0.25 cc of processes against one another with significant been reported in young athletes that engage 4% xylocaine at the L2-3 lumbar spine level force during extension maneuvers especially in repetitive lumbar extension maneuvers.7 over a 14-day interval. The patient’s VAS in patients with hyperlordotic posture. Baas- Additional epidemiologic research using a score changed from 6 to 2, she was able to

24 Orthopaedic Practice volume 31 / number 1 / 2019

6938_OP_Jan.indd 24 12/17/18 12:55 PM complete a conditioning program, return to in light weight training regularly without exercises, and continuation of the patient’s full activity, and she remained asymptomatic exacerbation of his past or current com- routine lumbar flexion exercises. SeeTable 2. at a two month and 12 months follow-up. plaints if the extremes of lumbar extension There is a dearth of literature regarding were avoided. OUTCOMES physical therapy intervention for Baastrup’s The patient attended 5 physical therapy disease. Singla et al5 reported successful man- Physical Examination sessions (once per week) post initial evalua- agement of back pain in a 67-year-old male Physical examination revealed no visible tion over a 7-week period. During assessment with Baastrup’s disease treated with muscle atrophy of lumbar paraspinals. There was at week 5, the patient reported 0/10 pain relaxants and analgesics for one week followed focal tenderness with palpation of the mid- since the prior session, L3-4 interspace was by spinal flexion exercises. At a 6-month line of the lumbar spine, particularly at L3-4 no longer painful to palpation, multifidus follow-up the patient remained asymptom- spinous interspace and processes. Lumbar contraction had normalized, and an artho- atic. DePalma et al7 noted the failure of 4 flexion, extension, side bending right, and kinematic assessment revealed normal L3 seg- weeks of nonsteroidal anti-inflammatory left range of motion was unrestricted but mental mobility. See Table 2, session 4 (week drugs and stabilization exercises in a previ- lumbar extension past neutral reproduced 5). A repeat lateral x-ray of the lumbosacral ously described case involving an 18-year- focal pain in the mid lumbar region. There spine was performed at the same facility by old female, collegiate basketball player with was no lower extremity muscle weakness the same technician using the same position- Baastrup’s disease. Philipp et al16 purport that detected with manual testing. Bilateral mul- ing used during the pretreatment radiograph. physical therapy plays a key role in the long- tifidus deficit (left > right) was noted with See Figures 2 and 4. The radiograph dem- term management of Baastrup’s syndrome in prone contralateral leg lifting test. Arthro- onstrated evidence of reduced spinous abut- order to reduce interspinous strain and lor- kinematic assessment of the lumbar region ment of L3 on L4 as evidenced by increased dosis. However, they offer no research to sup- revealed segmental mobility loss of L3 flex- interspinous space, reduced sclerosis at the port this position. ion/right side bending/right rotation. previous L3-4 abutment site, and remodeling To our knowledge there has been no scalloped bone on the L4 spinous process. A report of successful physical therapy treat- Imaging Recommendations and Results modified Ferguson method of lumbosacral ment of low back pain in a patient with Baas- Post initial evaluation, it was agreed that angle measurement was performed to assess trup’s disease. The purpose of this report is imaging of the lumbar spine was indicated to potential differences in lordosis during the to present the results and clinical reasoning assess osteology integrity within the region of pre- and post-lateral x-rays. The lumbosacral associated with the treatment of a 62-year- pain. Anterior-to-posterior and lateral and angles differences were negligible. See Figures old male with Baastrup’s disease using manual focused lumbosacral lateral radiographs were 5 and 6. physical therapy as a primary intervention. obtained. The results are listed inTable 1. The posttreatment image findings were reviewed during session 5 (week 7) and CASE DESCRIPTION IMPRESSION deemed concordant with the clinical assess- Patient History Based on the subjective history, objective ment in which the patient was painfree, A 62-year-old male presented self-referred findings, and imaging studies a diagnosis of demonstrated normal multifidus contrac- to an outpatient physical therapy clinic with Baastrup’s disease in the context of lumbar tion, and normal segmental mobility of L3. reports of central low back pain unrelated to segmental dysfunction was highly probable. See Table 2. Session 5 (week 7). The patient injury. The patient reported a gradual onset A mutual decision was made to proceed with was discharged with a HEP of continued pas- of aching and focal pain, in the region of physical therapy as the first line of treatment. sive flexion exercise and multifidus re-educa- L3-4 spinous process of 3 months duration tion exercise, which was integrated into the that had worsened over that time. The pain INTERVENTIONS patient’s current fitness program. was worse with lumbar extension and with Treatment was progressed based on direct palpation of the L3 spinous process interval assessment and consisted of manual DISCUSSION but was relieved with flexion. The pain was therapy to address L3 movement restrictions In the case of Baastrup’s disease under rated at 4/10 at rest on a numeric pain rating and positional fault, a home exercise program consideration, it was postulated that arthro- scale. The patient had received no treatment (HEP) consisting of multifidus re-education kinematic dysfunction could be a contrib- for the condition but had just completed a 6-week prednisone taper for a dermatologic condition. However, he did not experience a reduction in back pain. Table 1. Pretreatment Anterior-to-Posterior, Lateral, and Coned View X-ray of the Lumbar A pertinent review of systems was nega- Spine Findings

tive for lower extremity radiculopathy, weak- • Spinous process abutment at the interspace of L3-L4 (Figures 1 & 3) otherwise ness, or sensory change. The patient’s medical normal alignment of the lumbar spine with no evidence of hyperlordosis or scoliosis or history was significant for a remote, left L5 spondylolisthesis. pars fracture from a squat lift accident 32 years earlier but has had no related symptoms • Sclerosis was seen at the abutment surfaces of L3-4, and bone scalloping on the superior surface of L4 (Figures 1 & 3). Osteology was otherwise normal with no evidence of osteoporosis, for several years. The patient had also been fracture, or tumor. successfully treated with physical therapy for right side sacroiliac joint pain/dysfunction • Apophyseal cartilage loss and sclerosing arthritis changes were noted at L4-5 and L5-S1. Disc and gluteus medius weakness 6 years prior to space height was preserved at all visible levels. this encounter. The patient was otherwise in good physical health. He cycled and engaged • Visualized soft tissues appeared normal.

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6938_OP_Jan.indd 25 12/17/18 12:55 PM Table 2. Interval Assessment and Treatment Progression

Sessions Assessment Treatment Plan

Session 1 Pain: 4/10 (at rest) Joint Mobilization: Activation of Progress closed chain trunk (Week 1) L3 flexion/right side bending/right rotation to 1X 15 3-4x/week Palpation: Moderate tenderness L3-4 interspinous space rotation Continue spine flexion stretch Segment mobility: Marked restriction of L3 flexion/right side Therapeutic exercise: Closed chain 3-4x/week bending/right rotation trunk rotation 1 x10 reps (multifidus activation) Follow-up with PT in 1 week Neuromuscular: Multifidus deficit with contralateral leg lifting test Spine flexion stretch with floor mount • Left - contraction not palpable bar 30 sec duration, 3-4x/week • Right - contraction minimally palpable

Lateral lumbar x-ray (Pre RX): • abutment of L3-4 spinous process • pseudoarticulation at L3-4 interspinous space • scler osis of abutment surfaces of L3-4 • scalloped bone on the L4 spinous process

Session 2 Pain: 4/10 at rest. 0/10 X 1-day post 1st treatment Joint Mobilization: Activation of Progress closed chain trunk (Week 2) L3 flexion/right side bending/right rotation to 1X 20 3-4x/week Palpation: Moderate tenderness L3-4 interspinous space spinous rotation space Continue spine flexion stretch Therapeutic exercise: Closed chain 3-4x/week Segment mobility: Moderate restriction of L3 flexion/right side trunk rotation 1 x15 reps (multifidus bending/right rotation activation) Follow-up with PT in 1 week

Neuromuscular: Multifidus deficit with contralateral leg lifting test Spine flexion stretch with floor mount • Left - contraction minimally palpable bar 30 sec duration, 3-4x/week • Right – contraction distinctly palpable

Session 3 Pain: 2/10 at rest. 0/10 X 5 days post 2nd treatment Joint Mobilization: Activation of Progress closed chain trunk (Week 3) L3 flexion/right side bending/right rotation to 1X 25, 3-4x/week Palpation: Minimal L3 spinous process tenderness rotation Continue spine flexion stretch Segment mobility: Minimal segmental restriction L3 flexion/ Therapeutic exercise: Closed chain 3-4x/week right side bending/right rotation trunk rotation 1 x20 reps (multifidus activation) Follow-up with PT in 2 weeks Neuromuscular: Multifidus deficit with contralateral leg lifting test • Left - contraction distinctly palpable Spine flexion stretch with floor mount • Right - contraction distinctly palpable bar 30 sec duration, 3-4x/week

Session 4 Pain: 0/10 since completion of session 3 Joint Mobilization: Activation of Continue closed chain trunk (Week 5) L3 flexion/right side bending/right rotation to 1X 25, 3-4x/week Palpation: No L3 spinous process tenderness rotation Continue spine flexion stretch Segment mobility: No detectable segmental restriction L3 Therapeutic exercise: Closed chain 3-4x/week follow-up 2 weeks flexion/right side bending/right rotation (right equal to trunk rotation 1 x20 reps (multifidus contralateral side post session 4) activation) Requested repeat post treatment lateral radiograph of lumbar Neuromuscular: No palpable deficit of bilateral multifidus Spine flexion stretch with floor mount spine. Follow-up with PT post response with contralateral leg lifting test bar 30 sec duration, 3-4x/week x-ray

Session 5 Pain: 0/10 since session 3 Joint Mobilization: assessment of Discharge to self-care with (7 weeks) L3 flexion/right side bending/right home exercises and avoidance of Palpation: No L3 spinous process tenderness rotation hyperextension activities

Segment mobility: normal L3 flexion/right side bending/right Therapeutic exercise: Closed chain Follow-up with PT PRN rotation (= to contralateral side) trunk rotation 1 x25 reps (multifidus activation) Neuromuscular: Normal bilateral multifidus response with contralateral leg lifting test Spine flexion stretch with floor mount bar 30 sec duration, 3-4x/week Lateral lumbar x-ray (Post RX): • incr eased interspinous space at L3-4 • r educed sclerosis of both L3 and L4 • r emodeling of scalloped bone on the L4 spinous process

26 Orthopaedic Practice volume 31 / number 1 / 2019

6938_OP_Jan.indd 26 12/17/18 12:55 PM Figure 3. Focal view of L3-4 interspace prior to physical therapy. Normal mode x-ray mode clearly demonstrates loss of interspinous space and abutment of L3-4 spinous processes.

Figure 1. Standing lateral x-ray of lower lumbar spine prior to physical therapy. L3-4 interspinous space Figure 4. Focal view of L3-4 demonstrates evidence of spinous interspace post physical therapy. process abutment, pseudo- Color inversion mode x-ray clearly Figure 6. Posttreatment x-ray lower articulation, sclerosis at the demonstrates increased L3-4 lumbar spine. abutment surfaces, and bone interspinous space and decreased Lumbosacral Angle (Ferguson scalloping on the superior surface degenerative changes. Method) 46.8°. of L4.

uting etiology to lumbar spinous process abutment and subsequent back pain. This notion has theoretical support in anatomy and biomechanical literature. The biomechanics of the lumbar spine are largely regulated by apophyseal joint orientation. There is an abrupt transition of the apophyseal joint orientation at the thoracolumbar junction from frontal plane to near sagittal plane orientation in L1-2 with a very gradual transition toward the frontal plane in the mid lumbar region to near the frontal plane orientation of L5-S1.17-19 This orientation results in facilitation of sagittal plane motion in the upper and mid lumbar seg- ments. Chronic lordosis posture or high force acute extension in the context of sagittal plane bias has the potential to slide the inferior facets of a superior lumbar segment beyond physiologic range until they impact Figure 2. Standing lateral x-ray of the lamina or until the spinous processes lower lumbar spine post physical abut.2,17,20 Based on these known biome- therapy. chanics and clinical findings of the patient L3-4 interspinous space under consideration, it was postulated demonstrates evidence of increased that apophyseal hypomobility dysfunction space, reduced sclerosis at the Figure 5. Pretreatment x-ray lower could sustain a lumbar segment in exten- abutment surfaces, and bone lumbar spine. sion resulting in chronic spinous abutment remodeling of scalloped bone on Lumbosacral Angle (Ferguson as seen in Baastrup’s disease. The positive the superior surface of L4. Method) 47.1°. clinical outcome and increased interspinous space at L3-4 seen on radiographic images

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6938_OP_Jan.indd 27 12/17/18 12:55 PM following mobilization in this case supports issue; and reassessment of L3-4 spinous pro- or other factors that decrease interspinous this notion. cess interspace and surrounding structures via distance. Elimination of back pain concur- Early concepts in manual physical therapy comparison of pre and post manual therapy rent with radiographic evidence of increased emphasized assessment and treatment of seg- x-rays. Results included (1) patient report of L3-4 interspinous space and diminution of mental joint function including that of the 0/10 pain at discharge, (2) therapist report degenerative changes in the patient under spine.21 There has been considerable research of restoration of L3 segmental mobility, (3) consideration highlights the potential util- demonstrating effectiveness of segmental and radiographic evidence of increased L3-4 ity of manual physical therapy intervention. assessment and treatment of spinal pain and interspace as well as evidence reduced scle- This case eportr highlights the possibility of dysfunction,22-26 however, Trijffel et al27 found rotic changes and remodeling of scalloped segmental lumbar mobility dysfunction as an that the rationale, methodology, and applica- bone. These esultsr provided correlative evi- additional etiology of spinous abutment and tion to clinical reasoning and treatment using dence for the utility of manual therapy assess- pain associated with Baastrup’s disease. Fur- manual therapy varied among therapists. ment and treatment of Baastrup’s disease in ther research involving manual therapy and Additionally, some of the early postulates of this patient. dynamic imaging is needed to determine the spinal motion segment assessment and treat- There were limitations in this case study prevalence of patients with Baastrup’s disease ment are being challenged based on lack of that constrain conclusions that can be drawn related to segmental spine dysfunction and intertester reliability, validity, and definitive and extrapolated to other patients with Baas- the effectiveness of manual physical therapy mechanism(s), particularly in the treatment trup’s disease. First, the etiology of Baastrup’s as a conservative intervention in that cohort of nonspecific low back pain.28-32 disease can be from causes other than seg- of patients. It must be noted however, that in the mental movement dysfunction and positional case under consideration there was clinical fault. These causes can be multifactorial and REFERENCES and radiographic evidence that the patient’s include hyperlordosis, intrinsic morphology pain had identifiable etiology and mecha- of the spinous process, pseudoarticulation 1. Edling L. Christian Ingerslev Baas- nism. Thus, the intended mechanism for between the processes, and loss in disc.2,3,42 trup: in memoriam. Acta Radiol. manual therapy intervention was clear; cor- Another limitation when applying findings 1951;35(40:326-330. rection of L3 hypomobility and position of this study to all patients with Baastrup’s 2. Baastrup CI. On the spinous processes fault to arrest spinous abutment and pain. disease is that the patient in this case had only of the lumbar vertebrae and the soft The ability to correct lumbar spine segmen- experienced symptoms for 3 months dura- tissues between them, and on pathologi- tal hypomobility and position with manual tion and had only modest arthritic changes cal changes in that region. Acta Radiol. therapy is supported in the animal, cadaver, at the abutting interspinous space. As previ- 1933;14(1):52-55. and human reseach.33-38 Additionally, pre- ously noted, patients with more advanced 3. Kwong Y, Rao N, Latief K. MDCT find- and posttreatment radiographs enabled cases of Baastrup’s disease may have devel- ings in Baastrup disease: disease or normal correlative assessment of the validity of the oped significant interspinous bursitis, osteo- feature of the aging spine? AJR Am J practitioner’s manual pre- and post-segmen- phytosis of spinous processes, interspinous Roentgenol. 2011;196(5):1156-1159. doi: tal mobility testing. It could be reasonably ligament inflammation and hypertrophy, 10.2214/AJR.10.5719. argued that variance in the lumbosacral lor- and spinous process fracture2,3,42,43 which 4. Lamer TJ, Tiede JM, Fenton DS. Fluo- dosis in the pre- and post-lateral spine x-rays would limit or eliminate potential efficacy roscopically guided injections to treat could have accounted for the increased of correcting segmental hypomobility and or “kissing spine” disease. Pain Physician. interspace seen posttreatment. However, position. Lastly, pre- and post-MRI imaging 2008;11(4):549–554. measurement of the lumbosacral angle with of dynamic movement similar to that per- 5. Singla A, Shankar V, Mittal S, Agarwal a modified Ferguson technique with the formed by Xia et al43 to assess in vivo range A, Garg B. Baastrup’s disease: the kissing patient in weight bearing demonstrated only of motion of the lumbar spinous processes spine. World J Clin Cases. 2014;2(2):45- 0.3° reduction in lordosis in the posttreat- would have been more representative of the 47. doi: 10.12998/wjcc.v2.i2.45. ment film. Performance of this measure- spinal mechanics associated with activities of 6. Rajasekaran S, Pithwa YK. Baastrup's ment on lateral lumbar films in standing daily living that could exacerbate the symp- disease as a cause of neurogenic claudica- has been previously reported.39 The reliabil- toms of patients with Baastrup’s disease. This tion: a case report. Spine (Phila Pa 1976). ity of this modified technique has not been type of imaging procedure could also provide 2003;28(14):E273-275. established. However, the small variance in the therapist considering manual therapy 7. DePalma MJ, Slipman CW, Siegelman E, et al. Interspinous bursitis in an athlete. J radiographic measurement of pre- and postintervention with greater insight into seg- Bone Joint Surg Br. 2004;86:1062-1064. treatment lumbosacral angles suggests that mental movement dysfunction and the best 8. Beks JW. Kissing spines: fact or the increased interspinous space seen on the treatment approach to resolve it. While this fancy? Acta Neurochir (Wien). posttreatment film was due to a change in level of diagnostic movement assessment was 1989;100(3-4):134-135. segmental position. Therefore it was not a not indicated for this case, it could be a con- 9. Yahia L, Newman N. A scanning electron result from variance in lordosis in pre- and sideration for controlled studies involving microscopic and immunohistochemical posttreatment x-rays. patients with Baastrup’s disease in the future. study of spinal ligaments innervation. Outcome measures considered in this Ann Anat. 1993;175(2):111-114. case included patient report of posttreatment CLINICAL APPLICATION 10. Bywaters E, Evans S. The lumbar pain levels on 0/10 scale for which valid- Baastrup’s disease or Kissing Spine Syn- interspinous bursae and Baastrup's syn- ity, reliability, and responsiveness have been drome has previously been described as 40-42 drome. An autopsy study. Rheumatol Int. established; segmental mobility of L3 as abutment of the posterior aspect of adjacent 1982;2(2):87-96. determined by manual therapy reassessment spinous processes due to aberrant morphol- for which only intratester reliability was an ogy, hyperlordosis, degenerative changes,

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6938_OP_Jan.indd 28 12/17/18 12:55 PM 11. Filippiadis DK, Mazioti A, Argentos S, 23. Donaldson M, Petersen S, Cook C, manual therapies. J Manipulative Physiol et al. Baastrup’s disease (Kissing Spines Learman K. A prescriptively selected Ther. 2006;29(5):341-346. Syndrome): a pictorial review. Insights nonthrust manipulation versus a 33. Colloca CJ, Keller TS, Harrison DE, Imaging. 2015;6(1):123-128. doi: therapist-selected nonthrust manipulation Moore RJ, Gunzburg R, Harrison DD. 10.1007/s13244-014-0376-7. Epub 2015 for treatment of individuals with low back Spinal manipulation force and duration Jan 13. pain: a randomized clinical trial. J Orthop affect vertebral movement and neuromus- 12. Maes R, Morrison W, Parker L, Sch- Sports Phys Ther. 2016;46(4):243-250. cular responses. Clin Biomech (Bristol, weitzer ME, Carrino JA. Lumbar doi: 10.2519/jospt.2016.6318. Avon). 2006;21(3):254-262. interspinous bursitis (Baastrup disease) in 24. de Oliveira RF, Liebano RE, Costa Lda 34. Gál J, Herzog W, Kawchuk G, Conway a symptomatic population: prevalence on C, Rissato LL, Costa LO. Immediate PJ, Zhang YT. Movements of vertebrae magnetic resonance imaging. Spine (Phila effects of region-specific and non-region- during manipulative thrusts to unem- Pa 1976). 2008;33(7):E211–215. doi: specific spinal manipulative therapy in balmed human cadavers. J Manipulative 10.1097/BRS.0b013e318169614a. patients with chronic low back pain: a Physiol Ther. 1997;20(1):30-40. 13. Okada K, Ohtori S, Inoue G, et al. Inter- randomized controlled trial. Phys Ther. 35. Keller TS, Colloca CJ, Gunzburg R. spinous ligament lidocaine and steroid 2013;93(6):748-756. doi. 10.2522/ Neuromechanical characterization of in injections for the management of Baas- ptj.20120256. Epub 2013 Feb 21. vivo lumbar spinal manipulation. Part I. trup's Disease: a case series. Asian Spine 25. Bronfort G, Haas M, Evans RL, Bouter Vertebral motion. J Manipulative Physiol J. 2014;8(3):260-266. doi: 10.4184/ LM. Efficacy of spinal manipulation Ther. 2003;26(9):567-578. asj.2014.8.3.260. Epub 2014 Jun 9. and mobilization for low back pain 36. Colloca CJ, Keller TS, Gunzburg R. 14. Franok S. Surgical treatment of interspi- and neck pain: a systematic review Neuromechanical characterization of in nal osteoarthrosis (“Kissing Spine”). Acta and best evidence synthesis. Spine J. vivo lumbar spinal manipulation. Part II. Orthop Scand. 1943;14(1-4):127-152. 2004;4(3):335-356. Neurophysiological response. J Manipula- 15. Odelberg-Johnson G. So-called graft frac- 26. Fritz JM, Whitman JM, Childs JD. tive Physiol Ther. 2003;26(9):579-591. tures after Albee’s operation. Acta Orthop Lumbar spine segmental mobility assess- 37. Szulc P, Lewandowski J, Boch-Kmieciak Scand. 1933;4(1):63-77. ment: an examination of validity for J, Berski P, Matusiak M. The objective 16. Philipp LR, Baum GR, Grossberg JA, determining intervention strategies in evaluation of effectiveness of manual Ahmad FU. Baastrup’s disease: an often- patients with low back pain. Arch Phys treatment of spinal function disturbances. missed etiology for back pain. Cureus. Med Rehabil. 2005;86(9):1745–1752. Med Sci Monit. 2012;18(5):CR316-322. 2016;8(1):e465. doi: 10.7759/cureus465. 27. van Trijffel E, Plochg T, van Hartingsveld 38. Downie AS, Vemulpad S, Bull PW. 17. Neumann DA. Axial skeleton: osteology F, Lucas C, Oostendorp R. The role and Quantifying the high-velocity, low- and arthrology. In: Neumann DA, ed. position of passive intervertebral motion amplitude spinal manipulative thrust: a Kinesiology of the Musculoskeletal System: assessment within clinical reasoning and systematic review. J Manipulative Physiol Foundations for Rehabilitation. 2nd decision-making in manual physical Ther. 2010;33(7):542-553. doi:10.1016/j. ed. Saint Louis, MO: Mosby Elsevier; therapy: a qualitative interview study. J jmpt.2010.08.001. 2010:346-349. Man Manip Ther. 2010;18(2):111-118. 39. Hellems HK Jr, Keats TE. Measure- 18. Masharawi Y, Rothschild B, Dar G, et al. doi: 10.1179/106698110X12640740712 ment of the normal lumbosacral angle. Facet orientation in the thoracolumbar 815. Am J Roentgenol Radium Ther Nucl Med. spine: three-dimensional anatomic and 28. Maher C, Adams R. Reliability of pain 1971;113(4):642-645. biomechanical analysis. Spine (Phila Pa and stiffness assessments in clinical 40. Jensen MP, Turner JA, Romano JM, 1976). 2004;29(16):1755-1763. manual lumbar spine examination. Phys Fisher LD. Comparative reliability and 19. Beresford ZM, Kendall RW, Willick SE. Ther. 1994;74(9):801-809; discussion validity of chronic pain intensity mea- Lumbar facet syndromes. Curr Sports 809-811. sures. Pain. 1999;83(2):157-162. Med Rep. 2010;9(1):50-56. doi: 10.1249/ 29. Binkley J, Stratford, P, Gill C. Inter- 41. Alonso F, Bryant E, Iwanaga J, Chapman JSR.0b013e3181caba05. rater reliability of lumbar accessory JR, Oskouian RJ, Tubbs RS. Baastrup’s 20. el-Bohy AA, Yang KH, King AI. motion mobility testing. Phys Ther. disease: a comprehensive review of Experimental verification of facet load 1995;75(9):786-792; discussion 793-795. the extant literature. World Neurosurg. transmission by direct measurement of 30. Phillips DR, Twomey LT . A comparison 2017;101:331-334. doi: 10.1016/j. facet lamina contact pressure. J Biomech. of manual diagnosis with a diagno- wneu.2017.02.004. Epub 2017 Feb 10. 1989;22(8-9):931-941. sis established by a uni-level lumbar 42. Pinto PS, Boutin RD, Resnick D. 21. Farrell JP, Jensen GM. Manual therapy: a spinal block procedure. Man Ther. Spinous process fractures associated critical assessment of role in the pro- 1996;1(2):82-87. with Baastrup disease. Clin Imaging. fession of physical therapy. Phys Ther. 31. Landel R, Kulig K, Fredericson M, Li B, 2004;28(3):219-222. 1992;72(12):843-852. Powers CM. Intertester reliability and 43. Xia Q, Wang S, Passias PG, eta l. In vivo 22. Szulc P, Lewandowski J, Boch-Kmieciak validity of motion assessments during range of motion of the lumbar spinous J, Berski P, Matusiak M. The objective lumbar spine accessory motion testing. processes. Eur Spine J. 2009;18(9):1355- evaluation of effectiveness of manual Phys Ther. 2008;88(1):43-49. 1362. doi: 10.1007/s00586-009-1068-8. treatment of spinal function disturbances. 32. Khalsa PS, Eberhart A, Cotler A, Nahin Epub 2009 Jun 19. Med Sci Monit. 2012;18(5):CR316-322. R. The 2005 conference on the biology of

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6938_OP_Jan.indd 29 12/17/18 12:55 PM Clinical Application: Physical Examination Procedure to Assess Hip Joint Damien Howell, PT, DPT, OCS Synovitis/Effusion

Damien Howell Physical Therapy, Richmond, VA

ABSTRACT • To suggest that invasive measurement Circumferential measures of the hip joint The purpose of this article is to describe a using volume arthrocentesis is indicat- raise some suspicion of significant joint effu- physical examination procedure that can be ed4 sion, but it would be helpful if additional used to infer the presence of clinically signifi- • To suggest that intervention to address physical examination could provide support cant hip joint effusion. The clinical examina- possible synovitis is indicated5 for the same.11 Girth measures are not sensi- tion procedure is operationally defined. The • The early identification of synovitis re- tive or responsive enough to use as clinical findings of the examination procedure can lated to systemic arthritic conditions, guidelines in post orthopedic knee surgery be used to recommend additional diagnostic and monitoring and managing a sys- protocols.5 imaging, and can assist in providing guidance temic arthritic condition There is a need for a physical examina- and objective criteria to modify rehabilitation • To provide guidance and objective cri- tion process that can be used to make infer- protocols. The operational description of the teria to adjust rehabilitation protocols5 ences regarding the presence and quantity examination procedure provides a starting Studies of knee and ankle joint effusion of joint effusion at the hip joints. This can point for research to investigate diagnostic have provided evidence that joint effusion further justify the need for diagnostic imag- accuracy (reliability, sensitivity, sensitivity, can cause muscular inhibition adversely ing to help determine the extent of effusion and likelihood ratios) for this method. affecting rehabilitation and recovery.6-8 Hip and tissues involved, which can further assist joint effusion is a significant contributor to to identify whether the swelling is intra- or Key Words: hip, evaluation, pathology, gluteal muscle inhibition.7 It is likely the extracapsular. There is a need for physical clinical decision making arthrogenic muscle inhibition process occurs examination procedure of the hip joint effu- at the glenohumeral joint; however, this con- sion that the clinician can use to adjust the BACKGROUND cept has not been investigated.8 amount of exercise and to determine progres- Synovitis occurs in association with con- Observation and measurement of joint sion through rehabilitation protocols. ditions such as rheumatoid arthritis, gout and effusion can be a valuable sign to determine lupus, etc. It can also be seen in patients with criteria for progression through stages of PURPOSE osteoarthritis. Chronic synovitis can lead to post-op protocols.9 As seen in Table 1, clini- The purpose of this article is to describe a joint destruction. Symptoms of synovitis are cians at the University of Delaware propose physical examination procedure that can be joint pain, swelling, and nodules. Tender- the symptom of pain, and the objective sign used to infer the presence of clinically signifi- ness is not a very good indicator of synovitis. of observation of joint effusion in the knee cant hip joint effusion. Synovitis is an important feature in man- joint as criteria to guide whether to have the The following concepts were considered agement of musculoskeletal pain problems patient do more exercise/activity; decrease in the development of the unique physi- and is indirectly manifested as joint effusion amount of exercise/activity, or to keep the cal examination procedure. The examina- or swelling.1 Just as there are differences in amount of exercise activity at the same level.5,9 tion procedure must demonstrate inter- and how we measure pain, there are differences At the hip joint, signs of joint synovitis intra-rater reliability. in how we detect joint synovitis or joint effu- and effusion are a bit more difficult to recog- The assessment requires collecting sup- sion. The prevalence of significant synovitis is nize because of the depth of the hip joint and portive subjective history and information. difficult to determine because of thearying v size/volume of the large gluteal muscles.10 Physical examination looking for joint effu- diagnostic techniques and it is likely under reported.2 There is wide variation as to how knee joint effusion is observed and reported. Table 1. Guide Using Joint Soreness and Joint Effusion to Progress Exercise or Rehab A majority of the unstandardized clinical tests Protocol to assess joint effusion in knee osteoarthritis

have relatively low intra- and inter-observer Eligible to progress No joint soreness after last No evidence of joint effusion reliability.3 Examination and documentation exercise/protocol session of joint effusion are an important part of the Eligible to progress Joint soreness after last session No evidence of increase or diagnostic and treatment processes.2 exercise/protocol gone by next morning change in amount of joint Physical examination of joint effusion is effusion used for a variety of purposes including: Stay with same amount of Joint soreness for 24 hours Physical examination demon- • To suggest that more sophisticated di- exercise or protocol level after last session strates increase in amount of agnostic imaging techniques should be joint effusion from previous visit used to quantify the amount of effusion Regress the amount of Joint soreness for more than one Physical examination demon- (diagnostic ultrasound, radiograph, or exercise or protocol level day after last session strates increase in amount of joint effusion from previous visit MRI)

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sion uses a ballottement maneuver, light quick poking motion looking for and/or feeling for displacement of fluid or sensation, or

rebound. In an effort to improve reliability of observation and measurement, the examination procedure needs to be performed in a standardized manner.

PROCEDURE Begin with visual observation of size, girth; shape of anterior hip joints. If the Figure 3. Squeeze, sweep, milking of problem is unilateral, look to see if there is Figure 3. Squeeze, sweep, milkingjoint of fluid joint in fluid a cephalic in a cephalic direction. direction. Figure 3. Squeeze, sweep, milking of joint fluid in a cephalic direction. symmetry or asymmetry (Figure 1).

The patient lies supine with the limb relaxed with the hip joint in position of relative extension and medial rotation. Palpate the uninvolved side first in order to establish a relative baseline of normalcy or benchmark Figure 1. Note the asymmetry of to compare the involved side.Figure 1. Note the asymmetryshape of shape (bulge) (bulge) on onthe the right right side side (yellow arrow). Lightly palpate the anterior aspect of the (yellow arrow).

hip joint, uninvolved hip joint first, assessing the degree of puffiness or swelling (Figure 2). If the patient has had surgery, the surgical scar can be used as a landmark. Place , one hand along the anterior lateral hip/thigh Figure 4. Perform a ballottementFigure maneuver 4. Perform light a quickballottement poking motion looking for and/or just distal to the hip joint. Press down and Figure 4. Perform a ballottementmaneuver, maneuver light, light quick quick poking poking motion motion looking for and/or feeling for displacement of fluid or sensation or rebound. in an upward direction towards the head, looking for and/or feeling for and squeeze the thigh and sweep slide along feeling for displacement of fluiddisplacement or sensation of or fluid rebound. or sensation or the anterior lateral aspect of the hip/thigh. rebound. Perform 2 to 3 sweep slides consecutively alternating hands. You are trying to move or performing a milking effect of the effusion Figure 2. Palpate the anterior aspect from the inferior anteriorFigure hip 2.joint Palpate capsule the anteriorof aspect uninvolved of uninvolved hip joint hip followed joint followed by by involved hip joint. 5 superiorly (Figure 3). involved hip joint. After the last sweep, sustain and hold the in osteoarthritis: current understanding squeeze while with the opposite hand palpates with therapeutic implications. Arthritis the anterior aspect of the hip joint. Compari- Res Therapy. 2017;19(1):18. son can be made between the amount of soft appropriate imaging studies for quantifica- 3. Mariar N, Callaghan MJ, Parkes MJ, fluid like material during palpation with and tion. In order for this test to be widely imple- Felson DT, O’Neilj TW. Clinical assess- without the manual sweep and squeeze pro- mented, a case series needs to be conducted to ment of effusion in knee osteoarthritis cedure (Figure 4). demonstrate the reliability and validity of this – Systematic review. Semin Arthritis If the hip pain and suspected joint effu- test. Data collection in various practice loca- Rheum. 2016;45(5):556-563. sion is unilateral, a rating of the magnitude of tions and by various providers to determine 4. Hansford BG, Stacy G. S. Musculoskel- feeling the soft fluid material can occur using similar findings and fur ther follow-up with etal aspiration procedures. Semin Intervent the following criteria: sonogram or MRI is warranted. Diagnostic Radiol. 2012;29(4):270-285. • no sign of joint effusion elativer to the values such as sensitivity, specificity, and like- 5. Sturgill LP, Snyder-Mackler L, Manal uninvolved side, lihood ratios could then be calculated. TJ, Axe MJ. Interrater reliability of • mild amount of joint effusion elativer a clinical scale to assess knee joint to the uninvolved side, and REFERENCES effusion. J Orthop Sports Phys Ther. • significant amount of joint effusion 2009;39(12):845-849. relative to the uninvolved side. 1. Roemer FW, Guermazi A, Fleson DT, 6. Palmieri-Smith RM, Villwock M, Downie et al. Presence of MRI-detected joint B, Hecht G, Zernicke R: Pain and DISCUSSION effusion and synovitis increases this effusion and quadriceps activation and A description of a physical examination risk of cartilage loss in knees without strength. Athl Tain. 2013;48(2):186-191. procedure that can be used to infer the pres- osteoarthritis at 30-month follow-up: 7. McVey ED, Palmieri RM, Docherty ence of clinically significant hip joint synovi- The MOST study. Ann Rheum Dis. 2011; CL, Zinder SM, Ingersoll CD. Arth- tis, and hip joint effusion has been presented. 70(10):1804-1809. rogenic muscle inhibition of subjects This examination procedure may provide 2. Mathiessen A, Conaghan PG. Synovitis valuable information regarding the presence (Continued on page 39) or absence of intraarticular fluid and propose

Orthopaedic Practice volume 31 / number 1 / 2019 31

6938_OP_Jan.indd 31 12/17/18 12:55 PM THE LUMBOPELVIC COMPLEX: ADVANCES IN EVALUATION AND TREATMENT Independent Study Course 28.3

Learning Objectives Description 1. Demonstrate an understanding of the value of assessing serious This course provides a comprehensive resource for the clinician who seeks pathologies and co-morbidities in managing patients with low back evaluation and treatment expertise for patients who suffer low back pain. pain. Particular emphasis is placed on defi ning the facets governing spinal sta- 2. Demonstrate an appropriate interpretation of the patient’s history bility, assessing movement patterns, and differentiating among types of and physical examination fi ndings into patterns that guide the pain and how each is effected in patients with low back pathology. Specifi c treatment. monographs are dedicated to the geriatric and pediatric populations. A 3. Recognize acute and subacute low back pain patterns and the unique feature of the course is the inclusion of 39 patient resource pam- rehabilitation that is prescribed for each. phlets that can be used for patient education. 4. Understand the theoretical basis for spinal stability and movement coordination. 5. Formulate a structured evidence-based examination algorithm Topics and Authors to identify relevant movement coordination impairments of the Acute ad Subacute Lumbopelvic Defi cits: Lumbosacral Segmental/ lumbopelvic complex. Somatic Dysfunction—Muhammad Alrwaily, PT, MS, PhD, COMT; 6. Apply the examination algorithm to develop optimal procedural Michael Timko, PT, MS, FAAOMPT interventions with regard to proper exercise dosing. 7. Defi ne different types of pain and identify common pain patterns. Acute, Subacute, and Recurrent Low Back Pain with Movement 8. Describe the relevant clinical anatomy of the lumbopelvic region to Coordination Impairments—Won Sung, PT, DPT, PhD; allow for accurate clinical examination and identifi cation of possible Ejona Jeblonski, PT, DPT sources of symptoms. Acute and Subacute Low Back with Radiating Pain—Robert Rowe, PT, 9. Understand the most common clinical presentations of low back DPT, DMT, MHS, FAAOMPT; Laura Langer PT, DPT, OCS FAAOMPT; pain with radiating pain conditions to provide a framework for the Fernando Malaman, PT, DPT, OCS, FAAOMPT; Nata Salvatori, PT, DPT, clinical examination. OCS, SCS, FAAOMPT; Timothy Shreve, PT, OCS, FAAOMPT 10. Understand the basis and progression of neuropathic pain and the development of chronic pain syndromes. Low Back in the Geriatric Population—Jacqueline Osborne, DPT, GCS, 11. Screen for possible sources of low back pain that require medical CEEAA; Raine Osborne, DPT, OCS, FAAOMPT; Lauren Nielsen, DPT, OCS, referral. FAAOMPT; Robert H. Rowe, PT, DPT, DMT, MHS, FAAOMPT 12. Use and interpret appropriate psychosocial screening tools to assist in identifying personal factors that infl uence patient management Adolescent Spine—Anthony Carroll, PT, DPT, CSCS, OCS, FAAOMPT; and prognosis. Melissa Dreger, PT, DPT, OCS; Patrick O’Rourke, PT, DPT, OCS; 13. Integrate research evidence to support the use of manual therapy, Tara Jo Manal, PT, DPT, OCS, SCS, FAPTA including high-velocity low-amplitude spinal mobilizations in the treatment of low back pain with radiating pain. Patient Educational Resources for the Spine Patient—W. Gregory 14. Discuss current evidence for non-pharmacologic and pharmacologic Seymour, PT, DPT, OCS; J. Megan Sions, DPT, PhD, OCS; interventions for older adults with low back pain. Michael Palmer, PT, DPT, OCS; Tara Jo Manal, 15. Identify one or more strategies for incorporating patient-centered PT, DPT, OCS, SCS, FAPTA care into the plan of care for an older adult with low back pain. Supplement: 39 Patient Resource Pamphlets 16. Develop an understanding of evidence-based management of adolescents with low back pain and when imaging is indicated. 17. Understand the concepts of exercise progression to prepare a Editorial Staff treatment program for an adolescent athlete, beginning with Christopher Hughes, PT, PhD, OCS, simple, early stage exercises progressing to advanced, sport-specifi c CSCS—Editor movements. Gordon Riddle, PT, DPT, ATC, OCS, SCS, CSCS—Associate Editor Continuing Education Credit Sharon Klinski—Managing Editor 30 contact hours will be awarded to registrants who successfully complete the fi nal examination. The Academy of Orthopaedic Physical Therapy pursues CEU approval from the following states: Nevada, Ohio, Oklahoma, California, and Texas. Registrants from other states must apply to their individual State Licensure Boards for approval of continuing education credit.

Course content is not intended for use by participants outside the scope of their license or regulation. For Registration and Fees, visit orthopt.org Additional Questions—Call toll free 800/444-3982

32 Orthopaedic Practice volume 31 / number 1 / 2019

6938_OP_Jan.indd 32 12/17/18 12:55 PM Orthopaedic Practice volume 31 / number 1 / 2019 33

6938_OP_Jan.indd 33 12/17/18 12:55 PM Join us for our Annual Orthopaedic Meeting Performance Enhancement Across the Lifespan

We invite physical therapists, *Residents, Fellows, PhD Students, and DPT students to join us for this exciting meeting! *See Resident, Fellow, and student attendance requirements on www.orthopt.org.

April 5 - 6, 2019 Omni Interlocken Resort, Denver, CO

Orthopaedic physical therapists treat patients across the lifespan and are committed to enhancing patient’s physical and functional performance. The Academy of Orthopaedic Physical Therapy’s 2019 Annual Orthopaedic Meeting will explore this responsibility specifically in the areas of rehabilitation dosing and patient mobility. From recovery after ACL injury and complications after total knee arthroplasty to assessment and training mobility in older adults, the team of experts will integrate best available evidence in hot topic areas and enhance participant learning with exciting and hands on laboratory breakouts.

On Day 1 of the program, participants will recognize the key challenges that face adolescents and young adults with ACL injury, recognize the impairments and the best evidence based interventions to mitigate risk and enhance their outcomes, and maximize their protection from re-injury and long term complications.

On Day 2, the unique role of blood flow restriction as an innovative exercise approach will be explored from the acute post-operative time period through the inevitable sarcopenia in geriatrics. The treating therapist will be inspired to enhance mobility of their older adult patients, rediscover how to evaluate and re-design mobility enhancing rehabilitation programs. The participants will also gain the knowledge and manual therapy skills to maximize mobility after total knee arthroplasty. This 2-day event will inspire therapists to question what they do and embrace what can be done as we enhance patient performance across the lifespan!

34 Orthopaedic Practice volume 31 / number 1 / 2019

6938_OP_Jan.indd 34 12/17/18 12:55 PM Schedule: Day one Schedule: Day two Friday, April 5, 2019 Saturday, April 6, 2019 7:45 am – 5:30 pm 8:00 am – 4:30 pm General Session: 7:45 AM – 10:15 AM General Session: 8:00 am – 10:30 am General Session Titles: General Session Titles: - Role of the Physical Therapist in Targeting Risk of ACL - Performance Enhancement Using Blood Flow Restriction Injury Training: From Athletes to Older Adults with Sarcopenia - Population Specific ACL Injury Prevention and Dosing - Challenges, Clinical Reasoning, and Innovations in Total - From the Clinic to the Field: Maximizing Functional Knee Arthroplasty Recovery after ACL Reconstruction - The Older Adult: How to Guide for Mobility Assessment - ACL injury begins with “A” and ends with “OA:” potential and Advanced Clinical Decision Making to change the outcome begins with you - Task-oriented Motor Learning Approach to Walking: From - Prevention of 2nd ACL injury in your current rehabilita- Athletes to Older Adults, the Aim is Expert Movers tion episode of care: Are we doing enough? Speakers: Johnny Owens, MPT; Michael Bade, PT, DPT, PhD, OCS, FAAOMPT; Speakers: Kevin R. Ford, PhD, FACSM; Jeffrey Taylor, PT, PhD, DPT, OCS, SCS, Jennifer Brach, PT, PhD; Jessie VanSwearingen, PT, PhD, FAPTA CSCS; Mark V. Paterno, PT, PhD, MBA, SCS, ATC; Laura C Schmitt, PT, Visit www.orthopt.org to view the key topics addressed during this general session MPT, PhD Visit www.orthopt.org to view the key topics addressed during this general session Concurrent Breakout Sessions: Following the general session on Saturday, four concurrent Concurrent Breakout Sessions: breakout sessions will be offered. The registrant will attend Following the general session on Friday, four concurrent three out of four breakout sessions following the morning breakout sessions will be offered. The registrant will general session, based on order of preference indicated attend three out of four breakout sessions following the on the registration form. Note: space is limited, therefore morning general session, based on order of preference attendee’s breakout sessions are assigned on a indicated on the registration form. Note: space is limited, first-come, first-serve basis. therefore attendee’s breakout sessions are assigned on a first-come, first-serve basis. Breakout Session 5: Clinical Application of Blood Flow Restriction Exercise Breakout Session 1: Lessons Learned from the Lab Hands-on Techniques to Provide Screening and Feed- Johnny Owens, MPT back to Reduce Risk of Primary ACL Injury Breakout Session 6: Kevin R. Ford, PhD, FACSM Key Manual Therapy Techniques and Strategies for Breakout Session 2: Maximizing Movement after Total Knee Arthroplasty Exploring the Role of the PT in Field-based Primary ACL Michael Bade, PT, DPT, PhD, OCS, FAAOMPT Injury Prevention and Rehabilitation Dosing with Wearable

Technology Breakout Session 7: Jeffrey Taylor, PT, PhD, DPT, OCS, SCS, CSCS Measuring Mobility Goes beyond Gait Speed: Get Up and Do it!

Breakout Session 3: Jennifer Brach, PT, PhD Objectively-informed Decision-making to Maximize Functional Recovery Breakout Session 8: Laura C Schmitt, PT, MPT, PhD Science and Practice – How to Restore the Motor Skill of Walking from Both Sides of the Street

Breakout Session 4: Jessie VanSwearingen, PT, PhD, FAPTA Targeted Rehabilitation to Reduce 2nd ACL Injury: Learn More: Addressing Risk Factors at all Phase of Rehabilitation The 2019 Annual Orthopaedic Meeting will be held at the beautiful Mark V. Paterno, PT, PhD, MBA, SCS, ATC award-winning Omni Interlocken Hotel. This beautiful property provides a luxurious retreat between Boulder and Denver. Nestled Friday April 5, 4:30 pm - 5:30 pm: against the backdrop of the Rocky Mountains, the hotel offers a “Eureka Hour” wealth of on-site experiences. Visit the following link for full meeting details, to register, and to reserve your guestroom: The last program of the day on Friday will be a hot off the presses, evidence rapid fire "5 slides in 5 minutes” session! Plan to stick around https://www.orthopt.org/content/education/2019-annual-ortho- for these research presentations and a Q&A wrap-up before our paedic-meeting/overall-meeting-description networking reception. Come join the dialogue! Additional Questions? Networking Reception: 5:30 – 7:30 PM Call toll-free: 800-444-3982 x2030 or visit our website: www.orthopt.org

Orthopaedic Practice volume 31 / number 1 / 2019 35

6938_OP_Jan.indd 35 12/17/18 12:55 PM Rehabilitation Outcomes Following Primary vs Susan Kelvasa, PT, OCS1 Secondary Repair of Ruptured Tibialis Anterior Prarthana Gururaj, PT, OCS1 Tendon: A Report of Two Cases

1Mercer Bucks Orthopedics, Hamilton, NJ

ABSTRACT 3 weeks and 5 days, nonweight bearing. He right foot due to perceived foot slap during The article presents two case reports was subsequently transitioned to a CAM walking. He reported that he was not sure of patients rehabilitated in the outpatient boot, partial weight bearing to full weight when his ‘slapping’ of the foot began but he setting following primary and secondary bearing as tolerated. He continued weight noticed it after he had been working on his repairs of the tibialis anterior tendons after bearing in the CAM boot using a straight bathroom floor on his hands and knees. He a complete rupture. Both patients had varied cane for another 3 weeks. The total immobi- had notable difficulty picking up his foot predisposing factors. The presence of a dor- lization time from surgery was 7 weeks and 5 to walk when he got off the floor and was siflexion lag during gait was an important days. Patient findings following immobiliza- unable to recall with certainty if he had been postoperative and post-rehabilitation deficit tion are found in Table 1. Upon discharge of on a plantar flexed foot when kneeling. His that has implications on gait and fall risk for the CAM boot the patient was fitted with a post examination MRI done by the ortho- patients and hence clinical practice for the lace up ankle brace. The postoperative proto- pedic surgeon showed a complete rupture of outpatient physical therapist. col can be found in Table 2. the tibialis tendon (Figure 1). The patient began physical therapy at The patient underwent a primary repair Key Words: dorsiflexion lag, primary and approximately 6.5 weeks following his sur- of the tibialis anterior tendon that involved secondary tendon repair, fall risk, gait gery. His treatment comprised initially of reattachment and reinforcement with an modalities as needed and therapeutic exer- AmnioGraft. He was placed in a CAM boot The incidence of tibialis anterior rup- cises with the goal of improving his ankle in a nonweight-bearing status for 6 weeks fol- ture followed by repair and rehabilitation is passive range of motion in all planes and lowed by weight bearing as tolerated also in uncommonly found in the literature. The strength for inversion, eversion, and plantar the boot. tibialis anterior is the primary dorsiflexor flexion. Hip and knee strengthening exercises Thepatient began physical therapy 6 of the foot along with the extensor hallucis to help improve ambulatory function were weeks postoperatively. All phases of his ther- longus and the extensor digitorum longus. also initiated. Active dorsiflexion strengthen- apy protocol (Table 3) were specified by his Acute tibialis anterior ruptures typically occur ing was initiated at 8 weeks postoperatively. surgeon based on the repair and physiological when there is a strong eccentric contraction. Additionally he received functional electri- healing. All changes and progression to pro- The patient will often report feeling a ‘pop’. cal muscle stimulation (FES) to the anterior tocol were provided by his surgeon during Acute ruptures are more common in younger tibialis muscle. The patient eceivedr 17 ses- the postoperative follow-ups. individuals. Chronic injuries are more attri- sions of therapy over a period of two months. Upon evaluation, the patient presented tional in nature. The subjects complain of a Upon discharge the patient was independent with a well healed surgical incision on the gradual development of a slapping foot or in all weight-bearing activity without assis- right foot with mild swelling of the dorsum difficulty clearing the floor when walking. It tive device. He reported overall improved of the foot. His gait was asymmetrical due to is usually without antecedent of trauma. It is ambulation. However, he reported fatigue at the boot. His range of motion and strength more common in the older population.1 the end of the day with some foot slap at that measures are found in Table 4. Patient 1 was a 71-year-old male with time which also was progressively improving. At the time of discharge from physical a personal medical history of diabetes mel- It should be noted the patient did not gain therapy, the patient had received 20 sessions litus, hypertension, and a BMI of 39.9. He full active dorsiflexion to end range. The sur- over approximately 10 weeks. Functionally, presented to the orthopedic surgeon with geon attributed this to a loss of mechanical the patient was able to ambulate without complaints of “slapping” of his left foot when advantage as a result of the change in tendon a limp. He was able to complete all activi- walking. He reported his symptoms had length. ties of daily living, including lawn mowing, been present for approximately 2 months, Patient 2 was a 73-year-old male with a driving, and small errands without difficulty. without any trauma or other apparent cause. BMI of 25.4. He presented to the orthopedic He could negotiate stairs without tripping. He believed that his symptoms could pos- surgeon with complaints of weakness in his He complained of occasionally feeling like sibly be related to a diabetic neuropathy prior to seeing the surgeon. The MRI findings showed a complete rupture of the tibi- Table 1. Patient 1: Postoperative Evaluation Findings (7 weeks post) alis anterior tendon with retraction above the Right Ankle Passive Range of Motion Strength (MMT) level of the extensor retinaculum. The surgical repair required the use of a Dorsiflexion Neutral, with complaint of stiffness Not assessed, active dorsiflexion was noted cadaveric tibialis anterior tendon graft with Plantar flexion Within Normal Limits 4/5, without complaint of stiffness/pain anchor due to the nature of the rupture. The Inversion 10°, without complaints 4/5, without complaint of stiffness/pain patient was immobilized postoperatively, Eversion 10°, without complaints 4/5, without complaint of stiffness/pain initially in a fiberglass cast, fixed at 90° for

36 Orthopaedic Practice volume 31 / number 1 / 2019

6938_OP_Jan.indd 36 12/17/18 12:55 PM Table 2. Patient 1: Postoperative Rehabilitation

Weeks 1-6 CAM boot Nonweight bearing No physical therapy ordered Physical therapy routine

Week 7 CAM boot Weight bearing as tolerated Passive ROM only by physical Rocker, resisted tubing plantar initiated physical therapy. therapy, all planes except plantar flexion, inversion, eversion. flexion C ybex knee extension and flexion isotonic strengthening in CAM boot.

Week 8 Initiate lace up brace Full weight bearing Continue passive ROM as above Rocker, resisted tubing as above. Added weight bearing exercises Seated active dorsiflexion with brace Step up, step down on 6" step. C ybex knee extension and flexion strengthening in lace up brace.

Week 9-10 Continue lace up brace Same as above Initiated simple stability exercises Single leg stance, standing active dorsiflexion.

Week 11-12 Wean off lace up brace Same as above Increased body weight exercises Squats, sit to stand, standing per MD orders lunges on step to self-mobilize ankle.

Week 13-14 No brace Same as above Progressed reps, sets on lower extremity strengthening

Week 15 No brace Patient discharged from therapy

Abbreviations: MMT, manual muscle test; WNL, within normal limits; CAM, controlled ankle motion; ROM, range of motion

his toes caught the floor but this was incon- sistent and he denied any falls. However, he acknowledged a fear of falling and challenge with the balance training during physical therapy. As part of discharge evaluation, the patient was asked to actively dorsiflex in standing (mimicking a heel strike) with his back against the wall, essentially attempt- ing to test dorsiflexor strength in standing through full range. There was approximately a 10° lag versus the nonsurgical leg. At a one year follow-up, both patients reported feeling very satisfied with their surgery and rehabilitation. Both continued to have occasional catching of the foot, mostly at the end of the day, but had not had any falls. Both patients were able to complete their daily routine without limitations.

DISCUSSION A retrospective study by Kopp et al2 of 10 patients, treated operatively for tibialis ante- Figure 1. Arrow points to empty tendon sheath of tibialis anterior. rior ruptures and used the American Foot and Ankle Society (AOFAS) Ankle Hindfoot scale and isokinetic testing, concluded that although patients in the study were satisfied with their functional outcomes, isokinetic significant differences between the dorsiflex- repairs from 1997-2012 that included 44 testing showed decreased dorsiflexion and ion strength of the operated and uninjured reported cases found that 69% had total inversion strength compared to the uninjured ankles. However, they did not note a statisti- recovery, 26% had moderate improvement, side. A study by Ellington et al,3 compris- cal difference between those treated with pri- and 12% had complications.4 The patients ing of 15 tibialis anterior repairs; 5 primary mary repairs vs. tendon transfers. in this case series demonstrated a dorsiflex- repairs and 10 with tendon transfers, using A literature review of 32 articles compris- ion lag and reported changes to their gait. dynamometry also concluded that there were ing of case reports of tibialis anterior tendon A long-term follow-up with a larger patient

Orthopaedic Practice volume 31 / number 1 / 2019 37

6938_OP_Jan.indd 37 12/17/18 12:55 PM Table 3. Patient 2: Postoperative Rehabilitation Protocol

Weeks 1-6 CAM boot Nonweight bearing No physical therapy ordered Physical therapy routine

Week 7 CAM boot Weight bearing as tolerated Passive ROM only all planes Home exercise program of initiated physical therapy except plantar flexion by heel slides, seated calf physical therapy stretches

Week 8 Initiate lace up brace Full weight bearing Strengthening – plantar flexion, Rocker passive ROM, Elastic inversion, eversion. Added weight tubing resisted strengthening, bearing exercises with brace seated stretches, Step up 6" step.

Week 9-10 Continue lace up brace Same as above Initiated active dorsiflexion, Initiated leg press, knee and hip simple stability exercises strengthening Single leg standing, seated active dorsiflexion, standing calf stretch

Week 11-12 Continue lace up brace Same as above Increased body weight exercises Squats, sit to stand, standing lunges on step to self-mobilize ankle

Week 13-14 Wean off the brace Same as above Progressed repetitions, sets on lower extremity strengthening

Week 15 No brace Patient missed this week of Swelling resolved in a week physical therapy due to an insect bite that caused swelling of the foot

Week 16-17 As above Initiated standing dorsiflexion Supported standing active strengthening dorsiflexion. eviewedR home exercise program, discharged from physical therapy

Abbreviations: MMT, manual muscle test; CAM, controlled ankle motion; ROM, range of motion

Table 4. Patient 2: Evaluation Findings While neither patient in this study REFERENCES 6 Weeks Postoperatively reported having fallen at their one year follow-up, each complained of fatigue with Passive Range Strength 1. Ortho Bullets. www.orthobullets.com. occasional catching of the foot. Both these Right Ankle of Motion (MMT) Accessed November 20, 2018. factors could potentially lead to incidences of Dorsiflexion 0° 2/5 2. Kopp FJ, Backus S, Deland JT, O’Malley falls. As a primary dorsiflexor of the foot, the MJ. Anterior tibial tendon rupture: Plantar flexion 10° 3/5 tibialis anterior plays a significant role in the results of operative treatment. Foot Ankle Inversion 10° 3/5 ankle strategy. The ankle strategy is a primary Int. 2007;28(10):1045-1047. Eversion 5° 3/5 contributor to the maintenance of static bal- 3. Ellington JK, McCormick J, Marion C, ance prior to the initiation of the hip strat- 5 et al. Surgical outcome following tibi- egy or stepping strategy. In older patients alis anterior tendon repair. Foot Ankle this may influence their gait and may also Int. 2010;31(5):412-417. doi:10.3113/ increase the risk of falls. Hence, adequate group would be useful to study the effects FAI.2010.0412. dorsiflexion strength along with balance 4. Zajonz D, Kohler L, Pretzsch M, et of a dorsiflexion lag on other ankle and foot and proprioceptive training, both static and dysfunctions or pathologies. al. Surgical treatment of tibialis ante- dynamic should assist in producing better rior tendon rupture. Der Orthopade. patient outcomes. It was demonstrated that CLINICAL APPLICATIONS 2015;44(4):303-313. Doi: 10.1007/ in these two cases, rehabilitation to improve s00132-015-3090-3 While a tibialis anterior repair may not range of motion, maximize strength as well be a commonly treated condition, therapists 5. Blazkiewiczm M, Wiszomirska I, as static and dynamic balance training was Kaczmarczyk K, Wit A. Types of falls treating such a patient should attempt to beneficial with the prevention of falls at one maximize the return of full dorsiflexion range and stategies for maintaining stability year follow-up. Medycyna Pracy and strength to prevent an active or passive on an unstable surface. . Further studies with larger sample sizes 2018;69(3):245-252. doi.org/10.13075/ dorsiflexion lag. Factors that could influence are needed to determine possible differences mp5893.00639. development of a dorsiflexion lag include between outcomes of primary and second- preinjury physical activity level, age-related ary repairs of the tibialis anterior. Follow- changes of muscle strength and mass, and up studies on the incidence of falls in these the loss of mechanical advantage as a result of patients are necessary to improve rehabilita- surgical technique and tendon length change. tive protocols and outcomes. 38 Orthopaedic Practice volume 31 / number 1 / 2019

6938_OP_Jan.indd 38 12/17/18 12:55 PM Wooden Book Reviews Rita Shapiro, PT, MA, DPT Book Review Editor

Book reviews are coordinated in collaboration with Doody Enterprises, Inc. mation about each joint and its muscular components. A key feature is the inclusion of a chapter introducing basic gait concepts. Since the ERRATUM purpose of the book is to provide basic concepts, licensed physical An error was noted in a book review printed in the last issue of or occupational therapists will find the information redundant. The Orthopaedic Physical Therapy Practice. The review titled, Observational more advanced concepts of muscle activation and movement pattern Gait Analysis: A Visual Guide, Slack Incorporated, 2018, $71.95, coordination are beyond the scope of this book. Future editions would ISBN: 9781630910402, 230 pages, Spiral Cover, Author: Adams, benefit from improved illustrations and links to online content. These Janet M., PT, MS, DPT; Cerny, Kay, PT, PhD changes would allow readers to better visualize the basic concepts of kinesiology and muscular interactions, as well as to compare normal Incorrectly cited as: and abnormal gait and posture. Despite these drawbacks, the book “The authors developed the observational gait analysis (OGA) and easily explains the fundamentals of kinesiology and movement science. created the first edition of the Rancho OGA manual. Dr. Adams is a professor at California State University, Long Beach, Where Dr. Cerny Jennifer Hoffman, PT, DPT, OCS has taught.” Select Rehabilitation

The text should have been written as: "Dr. Adams and Dr. Cerny developed an abbreviated version of the original observational gait analysis method and Rancho manual pio- neered by physical therapy staff under the direction of Dr. Jacquelin Perry in the mid-1960s. Dr. Adams is currently a professor at Califor- nia State University, Northridge."

The ditorE and reviewer regret the oversight. CLINICAL APPLICATION: PHYSICAL EXAMINATION Textbook of Kinesiology, Jaypee Brothers, 2018, $48 PROCEDURE TO ASSESS HIP JOINT ISBN: 9789352704521, 227 pages, Soft Cover SYNOVITIS/EFFUSION (Continued from page 31) Author: Bindal, V. D., PhD, LPT (USA) exhibiting functional ankle instability. Foot and Ankle Int. Description: This book teaches basic kinesiology concepts. 2005;26(12):1055-1061. Purpose: The purpose is to incorporate into one book all the fun- 8. Holm B, Kristensen MT, Bencke J, Husted H,Kehlet H, damentals of kinesiology and basic principles of human movement Bandholm T. Loss of knee-extension strength is related to knee science. The author meets his objectives using three distinct sections swelling after total knee arthroplasty. Arch Phys Med Rehabil. Audience: to examine the basic concepts of kinesiology. The primary 2010;91:1770-1776. audience is students and educators in physical education and physi- 9. Freeman S, Mascia A, McGill S. Arthrogenic neuromuscular cal and occupational therapy. Although not specifically stated by the inhibition: a functional investigation of existence in hip joint. author, the book is most appropriate for undergraduate students Clin Biomech (Bristol Avon). 2013;28(2):171-177. and educators as an all-inclusive textbook on the basic concepts of 10. Schweitzer ME, Magbalon MJ, Fenlin JM, Frieman BG, human motion. It is written by an esteemed physical therapy educator Ehrlich S, Epsein RE. Effusion criteria and clinical implications and author. Features: The first of the book's three sections provides of glenohumeral joint fluid: MR imaging evaluation. Radiology. a historical review detailing the evolution of the field of kinesiology. 1995;194(3):821-824. It continues with a review of basic anatomical and physical funda- 11. Fees M, Decker T, Snyder-Mackler L, Axe MJ. Upper extremity mentals of movement that leads into basic biomechanical concepts. weight-training modifications for the injured athlete. A clinical The book then dedicates nine chapters to kinesiology of each body perspective. Am J Sports Med. 1998;26(5):732-742. region. These chapters contain a review of the origin insertion, actions 12. Bierma-Zeinstra SM, Bohnen AM, Verhaar JA, Perns A, Ginai- of each muscle, and muscular interactions to initiate joint movement. Karamat AZ, Lameris JS. Sonography for hip joint effusion in The last section contains information on posture, basic principles of adults with hip pain. Ann Rheum Dis. 2000;59(3):178-182. gait, kinesiology of daily activities, and kinesiology concepts in the 13. Wahoff M, Dishavi S, Hodge J, Pharez JD. Rehabilitation after prevention of injuries incurred during sports. A glossary of kinesiology labral repair and femoracetabular decompression: criteria-based terms concludes the book. Assessment: This is an all-inclusive, easy progression through the return to sport phase. Int J Sports Phys to understand, kinesiology textbook for undergraduate students and Ther. 2014;9(6)813-826. educators in physical education and rehabilitation sciences. It presents fundamental concepts of kinesiology while including detailed infor-

Orthopaedic Practice volume 31 / number 1 / 2019 39

6938_OP_Jan.indd 39 12/17/18 12:55 PM PRESIDENT'S MESSAGE Practice Department to keep in touch with policy makers Lorena Pettet Payne, PT, MPA, OCS and regulators. Objective 2: Ensure physical therapists are aware of and com- If you are looking for new learning opportunities, would like pliant with workers’ compensation regulations (including WC, to network with peers or just take a refresher course, the OHSIG ADA, OSHA, EEOC etc.) has been working for you. Combined Sections Meeting is in Wash- • The OHSIG has sponsored webinars on OSHA first aid rule ington, DC, on Saturday January 26, 2019, at Walter E. Washing- and continues to share information as available. ton Convention Center, room 146A. Please join your peers for the • The OHSIG has made available a secure social network plat- OHSIG membership meeting at 6:45 a.m., immediately followed form that has hosted conversation regarding payment and by “Thinking Outside the Box: Improving Worker Health with policy. Ergonomics” - 8:00-10:00 a.m. The OHSIG Board will be meet- Objective 3: Educate PTs in best practices for managing working on Wednesday, January 23, 2019, 6:00-9:00 p.m., Marriott ers with health conditions Marquis, Pentagon room. Members are always welcome. Another • Work Rehab CPG as cited above. opportunity to elevate your knowledge is at NEXT, Chicago, Illi- nois Friday, June 14, 2019 at 3:00 p.m. – Putting Science Behind 5S Your Work Place! - Adopting the Promotion of Function to Support a Healthy Workforce. Additionally, check out the recent webinars presented by Steve Lean Manufacturing Philosophy for Allison on Functional Capacity Evaluations and another on Job the Health of the Work Force Analysis- Physical Demands Validation. These can be found with Submitted by Lorena Pettet Payne other archived podcasts on the OHSIG web page in the Academy of Orthopaedic Physical Therapy website at orthopt.org. Like many of my colleagues, I am on-site at numerous work A big thank you to all of the members that have reached out to places that range from manufacturing to service, to health care and the OHSIG for answers, with concerns, for information, or have retail operations. Several years ago, I was at a client company when offered a greater level of involvement within the group. My passion I noticed a piece of paper posted at a work station with this simple revolves around the ability of individuals to participate in mean- admonition “5S your work space.” I questioned the individual ingful work which in turn leads to healthy, productive communi- regarding the sign. She cited the various activities that keep the ties. My hope is that some of my enthusiasm and commitment is area efficient, most of which originated from her and her team- reflected in the work that board and many committee members mates. She explained that consistent and convenient organization have accomplished over the past 6 years. As I step away from my of her work area and making sure tools are in good working order obligations as OHSIG President I want to review the objectives helps her company remain efficient and, she admitted, it makes and progress which have served as our road map to the present and her happier. can continue to guide this dynamic group into the future. “Just in time” manufacturing or more commonly referred to as Objective 1: Position PTs as leaders and valuable contributors lean manufacturing is based upon the Toyota production system

OCCUPATIONAL HEALTH OCCUPATIONAL to workers’ compensation / occupational health structure and philosophy, which gained the attention of manufac- • TheWork Rehab CPG is a non-traditional CPG in that it is turers in the 1960s. The Toyota Way includes 14 major principles not based on a specific pathoanatomic model. We anticipate that the company has been built upon.1 A similar philosophy is publishing date in 2019. Six Sigma with origins within the Motorola Corporation in 1980. • Direct access with payment under work compensation re- Lean management is focused on eliminating waste and ensuring mains an area that needs work and the initiative of members efficiency while Six Sigma's focus is on eliminating defects and from all chapters. reducing variability using statistical analysis.2 • The operational definitions have a new name, Current Con- 5S is a critical process that is included in the broader approach of cepts in Occupational Health. The Functional Capacity Eval- lean management and will be introduced here. This same approach uation, Ergonomics, Rehab of the Acutely Injured Worker, can easily be adapted by physical therapists on the job site and in and Educators tool box are updated as of 1-2019. clinical practice to improve the value of services to all clients and • Increased awareness of physical therapist in the work space patients. When applied to physical therapist practice in injury pre- among policy makers, regulatory agencies has grown. Repre- vention, ergonomic intervention, return to work decisions as well sentatives from the OHSIG have met with the Department as more routine clinical services, the process of implementing all of Labor, OSHA administrators, members have commu- phases can be enlightening and, in the end, improve effectiveness. nicated with Social Security administration, we have given comment on ACOEM guidelines, members have presented at national meetings of self-insured employers. We have submitted member names to represent the profession on various advisory panels. The OSHIG collaborates with the APTA

40 Orthopaedic Practice volume 31 / number 1 / 2019

6938_OP_Jan.indd 40 12/17/18 12:55 PM 5S Phases3 investigate the cause, and recommend a change in the work area 1. Sort (Seiri) Getting rid of unnecessary items set up or in the tool used. This may produce a new standard with 2. Set in order (Seiton) Placing all necessary items in the opti- input from the workers and management which in turn will need mal place to be sustained. 3. Shine/Sweep (Seiso) Cleaning and inspecting the work place, 5S is only a small part of lean management philosophy. Lean tools, and machinery management is nimble and responsive to all customers. Kaizen 4. Standardize (Seiketsu) Standardize the processes used to sort, means “change for better” and is a perpetual concept that lean order, and clean companies embrace. It humanizes the workplace while eliminating 5. Sustain/Self discipline (Shitsuke) Autonomous continuation overly hard work (Muri). That is where physical therapists have so of the processes much to offer any business. It should not be overlooked that we SORT: Simple observation in a work area can identify if there should inspect our own business practices, implement lean man- are tools that are not needed or obsolete in the work space. This can agement thinking if only the 5S phases to become more effective, be distracting and may pose hazards if it limits the access to needed producing a product that all of our customers value. tools or supplies. Using information from the worker, make sure There are a number of resources related to lean management. that all items are easily available, unused, or unnecessary items are The business school near you may have short courses on the sub- removed. ject. Explore numerous books published on “the Toyota way” and SET IN ORDER: This is the important phase for input from become familiar with the fourteen principles4 on which efficiency the onsite physical therapist. Arrangement of the work area is criti- can be built. cal to avoid wasted or unnecessary movements. Critical assessment Address inquiries to [email protected] of the material handling tasks including horizontal reach, lifting operations, and placement of supplies will expose activities that REFERENCES OCCUPATIONAL HEALTH lead to needless injury. Recommendations for limiting reach dis- 1. Wikipedia. The Toyota Way. https://en.wikipedia.org/wiki/ tances or proper placement of heavier objects will be welcomed by The_Toyota_Way. Accessed November 1, 2018. the workers. 2. Wikipedia. Six Sigman. https://en.wikipedia.org/wiki/Six_ SHINE/SWEEP: Maintaining tools in good work order Sigma. Accessed October 1, 2018. decreases the need for more force or awkward postures. Examples 3. Wikipedia. 5S (methodology). https://en.wikipedia.org/ of this are not uncommon in my experience. I have seen workers wiki/5S_(methodology). Accessed October 1, 2018. using greater forces and awkward postures to complete a task when 4. Wikipedia. The 14 Principles. https://en.wikipedia.org/wiki/ they are using dull blades on rotary cutters, worn out sand paper The_Toyota_Way#The_14_Principles. Accessed November 6, on palm sanders, and a malfunctioning door on a compactor. 2018. STANDARDIZE: Communication of best practice is the first step to maintaining consistent quality or outcome. Physical therapist involvement in the orientation of new employees assists the company by giving consistent messages related to safety standards. Ergonomic principles, safety expectations, and reminders of general personal health management can be introduced and reinforced at each follow-up visit to the site. This phase reinforces the first 3 phases. SUSTAIN/SELF DISCIPLINE: Sustaining the process includes continual re-evaluation of efficiency and effectiveness. Physical therapists can identify areas of higher incidence of injury,

OCCUPATIONAL HEALTH LEADERSHIP Lorena Pettet Payne, President 2016-2019 [email protected] Brian Murphy, Vice President/ Education Chair 2017-2020 [email protected] Frances Kistner, Research Chair 2014-2020 [email protected] Michelle Despres, Communications Co-Chair 2017-2020 [email protected] Caroline Furtak, Communications Co-Chair 2017-2020 [email protected] Lori Deal, Nominating Committee Chair 2016-2019 [email protected] Trisha Perry, Nominating Committee Member 2017-2020 [email protected] Katie McBee, Nominating Committee Member 2018-2021 [email protected]

Orthopaedic Practice volume 31 / number 1 / 2019 41

6938_OP_Jan.indd 41 12/17/18 12:55 PM President’s Letter The importance of primary prevention for injuries in performing artists is necessary, as most injuries are related to overuse. The Annette Karim, PT, DPT, PhD Performing Arts Rehabilitation group is developing and adapting Board-certified Orthopaedic Clinical Specialist current screening tools to provide a comprehensive approach to Fellow of the American Academy of Orthopaedic Manual working with all performing artists, such as dancers, musicians, Physical Therapists theater performers, vocalists, figure skaters, and gymnasts. Dissem- inating information found in screenings from the clinicians to the performers is integral to creating change and assisting with injury prevention. Development of home programs and educational tools, including videos, websites, and other instructional aids such as mobile applications, is helping physical therapists to reach patients and create better adherence to prescribed exercise. Present- ers will be Kristen Schuyten, PT, DPT, MS, Board-certified Sports Clinical Specialist who was the physical therapist who traveled to PyeongChang for the 2018 Olympics with Team USA for Figure As we move forward into 2019, I would like to invite you to Skating, and Corey Snyder, PT, DPT, Board-certified Orthopaedic join us at the following PASIG events before, during, and after and Sports Clinical Specialist. CSM: The following meetings will be held in our AOPT bonus 2-day CSM Preconference Course room. Please note the time change. Musculoskeletal Sonography of the Lower Limb Focused in PASIG Fellowship Taskforce Q&A Thursday 1/24 12:00 p.m. Sport & Performing Arts, Tuesday 1/22 & Wednesday 1/23, 8:00 -1:00 p.m. (If interested, contact Laurel Abbruzzese, Fellowship a.m. - 5:00 p.m., Convention Center, 147A Taskforce Chair) This 2-day hands-on course will provide an introduction to PASIG Outreach Committee Thursday, 1/24 1:00 p.m. - 2:00 the use of diagnostic ultrasound, evaluation of the lower limb, p.m. (If interested, contact Marissa Schaeffer, Outreach Chair) and sonoappearance of lower limb pathology with specific con- PASIG Dancer Screening Networking/Q&A Thursday, 1/24 sideration to the sports and performing arts population. Day 1 2:00 p.m. - 3:00 p.m. (If interested, contact Mandy Blackmon, content will be suitable for those with no ultrasound experience, Dancer Screening Chair) or as a revision for intermediate users. Day 2 will discuss in depth PASIG Committees and Interested Volunteers Thursday musculotendinous and bony pathologies and their sonoanatomy 1/24 3:00 p.m. - 5:00 p.m. (Please contact the chair of the com- as it pertains to the hip, foot, and ankle. Attendees will learn mittee you are interested in) how to integrate the information obtained through musculoskel- 2-day Post-conference Course, (AOPT-PASIG and Univer- sity of Delaware co-sponsored) PERFORMING ARTS PERFORMING etal sonography to enhance their clinical examination and overall improved patient satisfaction and outcomes. At the completion of Emergency Medical Response Full Course (2 days) Sunday, this course, attendees will demonstrate understanding of the use of 1/27, 8:00 a.m. - 5:00 p.m. and Monday, January 28th, 8:00 a.m. diagnostic ultrasound in a clinical physical therapy setting, includ- - 4:00 p.m. (CEU Hours: 45) ing a basic knowledge of lower limb ultrasound evaluation and a Re-certification (1 day only for those expired ≤ 3 months) comprehensive understanding of the sonoappearance and exami- Sunday, 1/27 9:00 a.m. - 2:00 p.m. (CEU Hours: 7) https://sites. nation of musculotendinous and bony lower limb pathologies. udel.edu/ptclinic/2019-emergency-medical-response-course-2/ Presenters will include Megan Poll, Doug White, Marika Molnar, Please contact Rosie Canizares, our Vice President and Educa- and Scott Epsley, who have extensive experience in the use of real tion Chair, if you are interested in attending this post-conference time ultrasound imagery in augmenting the clinical examination off-site course: [email protected] of athletes and performing artists. A shout out to our PASIG members and OSU Performing Arts Fellows Tessa Kasmar and Tiffany Marulli presenting “Special PASIG Membership Meeting Considerations for the Dancer: Meeting the Needs of an Athlete Thursday, 1/24, 6:45 a.m. - 7:30 a.m., Convention Center, and Artist” at the 2019 NEXT conference in June. 146A Please get connected. The PASIG is you, me, and everyone we You do not need to be a member to join us at this early meet- can grab along the way to create something new. Reach out to ing. We would LOVE for you to become a PASIG member, but all one of us! Stay tuned for updates on PASIG programming, dancer are welcome. Please contact me if you have any questions. screening, fellowship, and membership in the monthly citation blasts and in our social media leading up to CSM. To belong to PASIG Educational Session our Facebook page, contact Dawn (Muci) Doran, and please tweet Olympian to Novice: Using Evidenced-based Screening for the about performing arts with us @PT4PERFORMERS Performing Artist, Thursday, 1/24, 8:00 a.m. - 10:00 a.m., Con- vention Center, 146A

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6938_OP_Jan.indd 42 12/17/18 12:55 PM It is with great pleasure that I introduce Megin Sabo John, PT, early diagnosis with physical examination and radiographs, espe- DPT, OCS, author of the following study. Thank you, Megin, for cially in management of the skeletally immature patient.14 The your contribution to our profession. purpose of this retrospective case report is to describe the interventions used during a progressive, full weight-bearing physical Ischial Tuberosity Avulsion Fracture therapy rehabilitation program for an IT avulsion fracture in an adolescent dancer. in an Adolescent Dancer: A Case CASE REPORT Report Evaluation Megin Sabo John, PT, DPT, OCS The patient was a 14-year-old female dancer participating in Minnesota Dance Medicine Foundation multiple dance genres in a Minnesota dance studio. She came as [email protected] a referral from a local sports and orthopedics walk-in clinic with a right adductor/hamstring strain. She reported pain at her right INTRODUCTION ischial tuberosity that had subsided only minimally since the injury Adolescent and young adult athletes suffer apophysitis and two weeks prior to the evaluation. She was not taking anti-inflam- avulsion fractures in various lower extremity locations, including matory medications and had not participated in dance since the the metatarsals, tarsals, tibia, fibula, femur, and pelvis.1 Report- 2-4 injury. She reported feeling a painful pull during her stretches, edly, these injuries are most common during a growth spurt, and followed the next day by an audible pop and pain while doing are associated with increasing tension force through the musculo- 4 anterior-posterior splits with the right leg forward. She reported tendinous unit, thus placing increased pull at ossification centers. no relevant medical history. During the evaluation she rated her An ischial tuberosity avulsion fracture is a disruption of the open 5,6 pain as high as 6/10 intermittently with walking, sitting, lifting her apophysis at the hamstring insertion to the pelvis. When placing leg into flexion, squatting, and bending forward. Her self-reported the hamstring in extreme range of motion, increased tensile force functional limitations also included dancing and running. 5 PERFORMING ARTS through the musculotendinous unit often causes this injury. The patient had a slight antalgic gait with decreased stance When adolescent dancers increase participation in athletic phase on the right lower extremity. Her pelvis was level in standing, activities,4 overuse injuries often occur at their tendons and apoph- 4,7,8 and she could bend and reach the floor but reported pain over her yses. Bowerman et al reports lower extremity injuries as the right ischial tuberosity. She had no pain with adductor stretching most common injury in young elite ballet dancers but found a lack or with resisted adduction. Measured with a single inclinometer of evidence clearly isolating growth, maturation, and poor lower placed mid-tibia (Figure 1) and allowing the hip to abduct slightly extremity alignment as risk factors to the onset of overuse injuries at end range, her uninjured left leg had hamstring flexibility during in this population.9 Pediatric athletes are at risk of injury to their ossification centers, with ischial tuberosity (IT) cases reported most frequently.9,10 Rossi and Dragoni10 collected 203 cases of acute avulsion fractures in the pediatric athlete, over 50% of the incidents (109), reported to be IT injuries. In a systematic review of avulsion fractures in the pelvis, Porr et al11 found the mechanism of injury poorly reported among the 66 case reports reviewed, making it difficult to link primary causes of injury to eccentric loading. However, they con- firmed that 88% of those cases were associated with physical activity, most frequently with kicking and running.11 Diagnosis of IT avulsion fractures is typically done with a series of anterior-posterior (AP) radiographs and physical examination.5,11-15 Tenderness to palpation over the IT and pain at the IT with manual muscle testing are common findings.5,6,12,13,15 The literature offers limited protocols for conservative rehabilitation of IT avulsion, but describes common themes5,6,16,17: limiting stress at the injury site during the initial stage of nonsurgical rehabilita- tion5,11-13,16-18 and avoiding vigorous or dynamic stretching until weight bearing is painfree and range of motion is restored.5,6,12,14 Some authors advocate for a period of reduced or nonweight bearing on the affected side to minimize tension6,17,18 while others advocate bed rest for the first 72 hours.5 After painfree activity has been achieved, return to sport may be initiated.5,6,12,16,17 When evaluating hamstring injuries in adolescent dancers, apophyseal injuries are an important differential diagnosis.5,6,17 These injuries can result from stretch-type passive movements, such as anterior-posterior splits, as well as forceful contraction-type movements, such as kicks and leaps.5,17,19 Individuals frequently report a “pop” with associated pain near the IT, similar to athletes diagnosed with hamstring strains,19 underlining the importance of Figure 1. Inclinometer placement for straight leg raise measurement.

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6938_OP_Jan.indd 43 12/17/18 12:55 PM a straight leg raise (SLR) of 130°. She had limited range of motion Interventions during the right involved SLR of 90° due to increased pain at the Direct interventions during her initial examination (Table 1) IT. Supine passive hip and knee flexion and active hip flexion included cross friction soft tissue mobilization of the right proxi- during seated psoas manual muscle testing produced pain. She mal hamstring musculotendinous unit. This approach reduces reported pain with prone right hip extension with the knee flexed tension at the IT while maintaining mobility of the hamstring but was able to hold against approximately 50% maximal contrac- musculotendinous unit20 and preventing adhesions.20,21 This was tion with 4-/5 strength during manual muscle testing (MMT) as followed by very gentle stretching of the right hamstring in supine compared to the uninvolved side. She had 4/5 strength on the right and ice massage22 over the ischial tuberosity and proximal ham- hamstring with prone MMT but with reported IT pain. She had string. Furthermore, prone hamstring curls with independent con- tenderness to the musculotendinous unit of the hamstring and centric movements and assisted eccentric lowering with the other over the IT. All other hip, sacroiliac, and lumbar special tests were foot due to pain with independent lowering were initiated. negative bilaterally including hip scour, FABER, FADIR, sacroiliac Initial interventions (weeks 2 to 7) implemented a period of provocative tests, neural tensioning, and lumbar central posterior relative (active) rest to prevent atrophy23 and to encourage patient to anterior mobilizations. compliance with activity modification.24 These interventions The patient had signs and symptoms consistent with an avul- included Pilates, floor barre, and core strengthening24 with full sion fracture at the right IT with a possible hamstring strain. weight bearing as tolerated. In terms of tissue loading, active rest, Positive findings included her age,6 a “pop” during her stretching and restoring ROM principles of progressive loading guided inter- routine,6,18 pain at the IT with active and passive hip flexion,6 and vention planning.25 tenderness over the IT.5,6,12,13,15 She was referred back to her refer- Approximately 4 weeks after the injury at her fourth visit, treat- ring provider for additional work-up including plain radiographs.6 ment progressed to partial loading with supine hooklying bridging The patient and parent were educated on the pathology findings using a posterior pelvic tilt26 to reduce hamstring tension (Figure and the referring medical provider was contacted to discuss find- 2). Calf and adductor strengthening was initiated in standing barre ings of the physical examination. exercises, including heel raises and ball squeezes between knees. Her plan of care recommended that she be seen twice a week Neuromuscular re-education was incorporated during week 4 with for 6 weeks, then once a week for 4 weeks. Emphasis would be Pilates based small leg circles in supine with the injured leg at 90° placed on neuromuscular re-education; therapeutic exercise; of hip flexion. Hamstring stretching and bridges with alternat- proprioception; balance; strengthening; and manual therapy to ing march were included at this phase due to 0/10 pain reported increase tissue extensibility, decrease muscle tension, and increase during these activities. range of motion (ROM). Week 5 progressed to Pilates based sidelying strengthening Differential diagnosis of an avulsion fracture could not be exercises (clamshell, bent knee abduction, and high clamshell) as ruled out until review of radiograph results; therefore, aggressive well as prone knee-straight hip extension exercises with a focus stretching of the right hamstring was avoided. The referring pro- on gluteus maximus activation. At this point she had increased vider ordered initial AP radiographs 19 days after the initial injury, passive ROM to 105° SLR on the right and decreasing levels of resulting in confirmation of a 1 mm avulsion fracture of the right pain. At this time, her mother reported that at her yearly physical tuberosity growth plate at the hamstring insertion. Conservative she presented with 5 inches of height growth in one year. A dra- nonsurgical treatment was recommended since the avulsion was matic growth spurt such as this could result in increased tensile minimally displaced.6 PERFORMING ARTS PERFORMING Table 1. Intervention Progression

Weeks postinjury and 2-3 weeks 4-5 weeks 6-7 weeks 8 weeks visit count 3 visits 3 visits 3 visits 2 visits

Right SLR ROM 90° 90° 98°-120° 133°

Intervention Hamstring frictions at Hamstring frictions at Week 6: Airplane balance, Balance MTJ, Gentle Seated HS MTJ, Bridging floor and Hamstring frictions, with passé and developpé, stretching, Ice Massage, ball, Heel raises, Adductor Continuation of previous Roman dead lifts, Single Active-assisted ROM for ball squeezes, Pilates leg exercises leg hip extension knee prone hamstring curls circles in supine, Sidelying bent to 90°, Nordic curls, hip strengthening Week 7: Pilates: rollover, jackknife, No manual treatment, scissors, & leg circles Bridge walkouts, Pilates supine leg scissors, Hamstring curls on ball Pain Rating 6/10 4/10 sitting Not rated 2/10 end range and grand plié

Posttreatment SLR ROM Not tested Week 5: 105° - 125° Right Not tested 105° Right 125° Left

Abbreviations: SLR, straight leg raise; ROM, range of motion; MTJ, musculotendinous junction

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6938_OP_Jan.indd 44 12/17/18 12:55 PM hamstring contraction with small ball squeezes in standing (Figure 3), “Airplane” balance,28-30 (Figures 4 and 5) and single-leg dead lifts31 for eccentric hamstring loading. Dance specific techniques were incorporated in balance exercises with passé développé movements into flexion, abduction, and extension. Return to dance progression was discussed with the patient and her mother, and she was encouraged to complete a daily 30-minute strengthening program for her core, hip rotators, and hamstring strengthening per initiated exercises. She was asked to rotate hamstring strengthening exercises every other day choosing among Swiss ball hamstring curls, single-leg dead lifts, end-range hamstring contraction with small ball squeezes in standing, Nordic curls, and bridge walkouts. She had no pain with leaps or splits during week 9; therefore, progressive strengthening (Figures 6 and 7) and balance interventions continued. The following week she measured arabesque Figure 2. Bridge with posterior pelvic tilt cuing. ROM (hip extension in standing) on the right leg at 70° of extension and 82° of extension on the left leg. The patient completed all stretching without pain and reported no pain with her home exercise program. force at the apophysis making her more susceptible to an avulsion She had a setback at 11 weeks postinjury reporting increased injury.27 pain to 3/10, primarily after completing her home exercise pro- At 7 weeks postinjury, she reported low levels of pain; while gram. Her hamstring strength was 4+/5 with MMT in prone and stretching she rated her discomfort at 2/10. Her SLR measured knee bent to 90°; she reported ischial tuberosity pain with SLR and PERFORMING ARTS 120° on the right and 130° on the left. Manual muscle testing of continued to have decreased SLR ROM at approximately 100° on the hamstring in prone with knee bent at 90°, revealed 5/5 static the right during the 12th week. She was referred at 13 weeks for strength with no pain during eccentric loading. Strengthening was follow-up radiographs, which showed a small line present at the progressed at this point with bridge walkouts, core stability train- ischial tuberosity but no distinguished fracture. Manual therapy ing with Pilates supine leg scissoring, and hamstring curls using was introduced again at 11 to 14 weeks with emphasis on soft a Swiss ball. Her SLR was near normal posttreatment measuring tissue release of the hamstring muscle belly and cross friction to 125°. adhesions within the musculotendinous unit. Two months postinjury she measured 133° SLR on the right with 2/10 pain at the IT and 135° SLR on the left (Table 2). Exer- Outcomes cise progression during weeks 8 and 9 included tall kneeling Nordic She began modified dancing at 14 weeks postinjury with restric- hamstring strengthening, Pilates core strengthening including jack- tions to the barre portion of ballet and tap dance classes. She began knife and rollover exercises to incorporate hamstrings, end-range to independently manage her strengthening at 15 weeks with one

Table 2. Intervention Progression

Weeks postinjury 9-10 weeks 11-12 weeks 14 weeks 15 weeks 27 weeks (6 months) and visit count 2 visits 2 visits 1 visit 1 visit 1 visit

Right SLR ROM Week 9: 135° Week 11: 90° Not tested 110° 122° Bilaterally no Week 10: not tested Week 12: 100° pain

Intervention Roman dead lifts, Hamstring frictions, Hamstring frictions, Airplane, Hamstring frictions, Airplanes, Standing Ice massage, Contract/relax right Roman Dead Lifts, Hamstring stretch, hamstring exercise Stretch hamstring hamstring Swiss ball hamstring reviewed hamstring with ball squeezes manually curls, bridges curls on ball and at variable speeds, (all progressed with bridges at various Nordic curls, Single dynamic surfaces) angles leg bridge, Ball Hamstring curls, Pilates: superman, Ball bridges, Down rolldown, leg circles, dog arabesque, Plank leg pull up/down arabesque Pain Rating 0/10 Week 11: 3/10 in Not rated 0/10 0/10 muscle Week 12: 0-2/10 Post treatment Not tested Slight increase 122° Right Not tested Not tested SLR ROM 137° Left

Abbreviations: SLR, straight leg raise; ROM, range of motion

Orthopaedic Practice volume 31 / number 1 / 2019 45

6938_OP_Jan.indd 45 12/17/18 12:55 PM Figure 5. Airplane balance into plié.

Figure 3. End-range hamstring contraction with small ball squeezes in standing. PERFORMING ARTS PERFORMING

Figure 6. Downdog arabesque.

emphasized ongoing hamstring and core strengthening as previously prescribed. She did not require any additional visits although Figure 4. Airplane balance. a follow-up visit was completed at 6 months.

DISCUSSION returning follow-up visit at 6 months. She was still slightly limited Throughout the rehabilitation program the patient’s mother to 122° of ROM during SLR on the right, but she reported no reported financial concerns. This consideration impacted the treat- pain. She had decreased hamstring strength on the right in prone ment plan, resulting in reduced attendance, as the original recom- testing 4/5 and reported some hamstring soreness and fatigue with mendation was therapy twice a week for 6 weeks followed by once dance. a week for 4 weeks. This change in frequency—despite patient edu- Discharge planning discussions with her and her mother cation aimed to ensure the dancer followed guidelines for return to

46 Orthopaedic Practice volume 31 / number 1 / 2019

6938_OP_Jan.indd 46 12/17/18 12:55 PM "entheses". Comp Biochem Physiol A Mol Integr Physiol. 2002;133(4):931-945. 3. d’Hemecourt P. Overuse injuries in the young athlete. Acta Paediatr. 2009;98(11):1727-1728. 4. Micheli LJ, Fehlandt AF. Overuse injuries to tendons and apophyses in children and adolescents. Clin Sports Med. 1992;11(4):713-726. 5. Metzmaker JN, Pappas AM. Avulsion fractures of the pelvis. Am J Sports Med. 1985;13(5):349-358. 6. Schiller J, DeFroda S, Blood T. Lower extremity avulsion fractures in the pediatric and adolescent athlete. J Am Acad Orthop Surg. 2017;25(4):251-259. 7. Hébert KJ, Laor T, Divine JG, Emery KH, Wall EJ. MRI appearance of chronic stress injury of the iliac crest Figure 7. Plank arabesque. apophysis in adolescent athletes. AJR Am J Roentgenol. 2008;190(6):1487-1491. 8. Anderson K, Strickland S, Warren R. Hip and groin injuries in athletes. Am J Sports Med. 2001;29(4):521-533. dance that included maintaining low level pain during stretching 9. Bowerman E, Whatman C, Harris, N, Bradshaw E. A review and strengthening—resulted in less guidance during more chal- of the risk factors for lower extremity overuse injuries in young lenging exercise progressions. This could account for the dancer’s elite female ballet dancers. J Dance Med Sci. 2015;19(2):51-56. increased pain and weakness at approximately 10 weeks postinjury 10. Rossi F, Dragoni S. Acute avulsion fractures of the pelvis in as the dancer increased load on the hamstring by incorporating adolescent competitive athletes: prevalence, location, and PERFORMING ARTS more dance-based movements at home. She reported compliance sports distribution of 203 cases collected. Skeletal Radiol. with the strengthening program but likely accelerated her home 2001;30(3):127-131. program too quickly due to lack of skilled supervision. Jumps and 11. Porr J, Lucaciu C, Birkett S. Avulsion fractures of the pelvis- a leaps were not introduced in the clinic, which may have been a qualitative systematic review of the literature. J Can Chiropr contributing factor as well. More comprehensive neuromuscular Assoc. 2011;55(4):247-255. re-education of her lower extremities, such as the dance specific 12. LaBella C. Common acute sports-related lower extremity jump protocol from the Harkness Center for Dance Injuries, as injuries in children and adolescents. Clin Pediatr Emerg Med. well as dynamic exercises for strength and agility could have been 2007;8(1):31-42. emphasized more toward the end of her rehabilitation. This case 13. Merkel D, Molony JT Jr. Recognition and management of report demonstrates a progressive full weight-bearing conservative traumatic sports injuries in the skeletally immature athlete. Int approach to IT avulsions in the skeletally immature patient, which J Sports Phys Ther. 2012;7(6):691-704. could assist with further studies as well as clinical management of 14. Gidwani S, Jagiello J, Bircher M. Avulsion fracture of the similar patients. ischial tuberosity in adolescents-an easily missed diagnosis. BMJ. 2004;329(7457):99-100. CONCLUSION 15. Akova B, Okay E. Avulsion of the ischial tuberosity in a Progressive treatment of adolescent patients with IT avulsion young soccer player: six year follow-up. J Sports Sci Med. fractures has been scantily outlined in the literature. While we 2002;1(1):27-30. know that athletes across various sports present with IT avulsions, 16. Anderson K, Strickland S, Warren R. Hip and groin injuries in we have no clear parameters for return to sport. We do know that athletes. Am J Sports Med. 2001;29(4):521-533. stretch-type hamstring injuries in dancers tend to have longer heal- 17. Schoensee SK, Nilsson KJ. A novel approach to treatment 32,33 ing time frames than sprinters, which could be significant when for chronic avulsion fracture of the ischial tuberosity in treating an adolescent athlete with a stretch-type avulsion at the IT. three adolescent athletes: a case series. Int J Sports Phys Ther. The literature discusses eccentric loading for hamstring injuries, 2014;9(7):974-990. but there is still a lack of guidance concerning full weight-bear- 18. Askling CM, Tengvar M, Saartok T, Thorstensson A. Proxi- ing physical therapy rehabilitation for an avulsion fracture with mal hamstring strains of stretching type in different sports: associated hamstring strain. This case eportr presents a conserva- injury situations, clinical and magnetic resonance imag- tive treatment for a 1mm avulsion fracture at the IT growth plate ing characteristics, and return to sport. Am J Sports Med. with return to dance at 14 weeks and full recovery reported at a 2008;36(9):1799-1804. 6-month follow-up. The progression of treatment and relative rest 19. Ogden JA. Skeletal Injury in the Child. 3rd ed. New York, NY: effectively returned this adolescent athlete to full athletic activity Springer-Verlag Inc.; 2000:817. without reoccurring pain or injury and should be considered in 20. Chamberlain GJ. Cyriax’s friction massage: a review. J Orthop patients with similar diagnoses. Sports Phys Ther. 1982;4:16-22. 21. Cyriax J. Textbook of Orthopaedic Medicine.Treatment by REFERENCES Manipulation, Massage and Traction. 11th ed. London, UK: 1. Liong S, Whitehouse R. Lower extremity and pelvis stress frac- BailiereTindall; 1984:19. tures in athletes. Br J Radiol. 2012;85(1016):1148-1156. 22. Reynolds JF, Noakes TD, Schwellnus, Windt A, Bowerbank P. 2. Benjamin M, Kumai T, Milz S, Boszczyk BM, Boszczyk Non-steroidal anti-inflammatory drugs fail to enhance healing AA, Ralphs JR. The skeletal attachment of tendons- tendon

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6938_OP_Jan.indd 47 12/17/18 12:55 PM PHYSICAL THERAPY MANAGEMENT OF CONCUSSION PHYSICAL THERAPYIndependent Study Course 28.1 Learning Objectives Editorial Staff 1. Describe the signs, symptoms, biomechanics, and pathophys- Christopher Hughes, PT, PhD, OCS, CSCS—Editor iology of a concussion. Gordon Riddle, PT, DPT, ATC, OCS, SCS, CSCS—Associate Editor of acute hamstring injuries treated with2. Cite physiotherapy. key risk factors for sustainingS Afr a concussion and indicators Sharon Klinski—Managing Editor Med J. 1995;85(6):517-522.MANAGEMENTleading to prolonged recovery following concussion. OF 23. Hoskins W, Pollard H. Hamstring injury3. Describe management- common clinical part profi les2: seen following concussion. Topics and Authors 4. Discuss the role of biomarkers in the evaluation andTHE manage- PASIGThe Basics of Concussion HAS treatment. Man Ther. 2005;10(3):180-190.ment of concussion. Anne Mucha, PT, DPT, MS, NCS 5. Understand negative consequences of poor concussion 24. Sabo M. Physical therapy rehabilitation strategies for dancers: a Cara Troutman-Enseki, PT, DPT, OCS, SCS management.CONCUSSION ARCHIVED COURSES qualitative study. J Dance Med Sci. 2013;17(1):11-17.6. Describe important guidelines for return to play following Physical Therapy Evaluation of Concussion sport-related concussion. 25. Liederbach M. General considerations for guiding dance injury AVAILABLEAnne Mucha, PT, DPT, AT MS, NCS 7. Discuss the advantages and Independentdisadvantages of various concus- StudyCara Course Troutman-Enseki, 28.1 PT, DPT, OCS, SCS rehabilitation. J Dance Med Sci. 2000;4(2):54-65.sion prevention strategies. Tim Ryland, PT, EdD(c), MPT, OCS, CBIS 8. Select evidence-based tools and outcome measureswww.orthopt.org for 26. Sherry MA, Best TM. A comparison ofclinical 2 rehabilitation evaluation and treatment pro- of concussion. Advanced Concussion Management grams in the treatment of acute hamstring9. Apply strains. key examination J Orthop and assessment methods for cervical/ Anne Mucha, PT, DPT, MS, NCS Learning Objectives thoracic spine, vestibular/oculomotor system, and exertion EditorialCara Troutman-Enseki, Staff PT, DPT, OCS, SCS Sports Phys Ther. 2004;34(3):116-125. 1. Describe the signs, symptoms, biomechanics,following concussion. and pathophys- ChristopherTim Ryland, PT, Hughes, EdD(c), MPT, PT, OCS, PhD, CBIS OCS, CSCS—Editor 27. Lau LL, Mahadev A, Hui JH. Common10. Appreciate lower limbthe role sports- of neurocognitive testing in concussionISC 20.3, Physical Therapy iology of a concussion. evaluation and management. GordonContinuing Riddle, Education PT, DPT, Credit ATC, OCS, SCS, CSCS—Associate Editor related overuse injuries in young athletes.11. Identify Ann clinical Acad profi Med les and treatment strategies for each 2. Cite key risk factors for sustaining a concussion and indicators SharonFifteen Klinski—Managing contact hours will be awarded Editor to registrants Singapore. 2008;37(4):315-319. concussion subtype: cervical, vestibular, ocular, formood, mi- the whoPerforming successfully complete the fi nal examination. Artist leading to prolonged recovery followinggraine, and cognitive/fatigue. concussion. The Orthopaedic Section pursues CEU approval from the 28. Leiderbach M. Perspectives on dance12. science Describe rehabilitation important indicators for return to activity following following states: Nevada, Ohio, Oklahoma, California, understanding3. Describe wholecommon body clinical mechanics profi andlesconcussion. seenfour key following principles concussion. Topicsand Texas. and Registrants Authors from other states must apply 13. Discuss the role of sleep in concussion management, and to their individual State Licensure Boards for of4. motor Discuss control the as role a basis of biomarkers for health movement. inemploy the interventions evaluation J Dance that Medand can bemanage- used to modify sleep The Basics of Concussion ISC 18.3,approval Dance of continuing education Medicine: credit. Sci. 2010;14(3):114-124.ment of concussion. dysregulation. Anne Mucha, PT, DPT, MS, NCS 14. Appreciate the infl uence of psychogenic factors in concussion Course content is not intended for use 29. White5. Understand KE. High hamstring negative tendinopathy consequencesmanagement. in 3 female of poor long concussion StrategiesCaraby Troutman-Enseki, participants for outside the the scope PT, DPT, OCS, SCS distance runners. J Chiropr Med. 2011;10(2):93-99.15. Describe common pharmacologic and non-pharmacologic of their license or regulation. management. treatment options for specifi c symptoms following concussion. 30. H6.ewitt Describe S, Mangum important M, Tyo guidelinesB, Nicks C. forFitness return testing to toplay following PreventionPhysical Therapy and Evaluation of Concussion DescriptionPHYSICAL THERAPY determinesport-related pointe readiness concussion. in ballet dancers. J Dance Med Sci. This monograph series provides in-depth coverage forCare the eval- Anneof Mucha,Injuries PT, DPT, MS, NCS 2016;20(4):162-167.7. Discuss the advantages and disadvantagesuation and treatment ofMANAGEMENTof concussion various by concus-a physical therapist. The Cara Troutman-Enseki, OF PT, DPT, OCS, SCS 31. Goom TS, Malliaras P, Reiman MP, Purdamauthors are recognizedCR. Proximal clinical experts in the fi eld of concussion sion prevention strategies. management. The basic pathophysiology underlying concussionto Dancers Tim Ryland, PT, EdD(c), MPT, OCS, CBIS hamstring8. Select tendinopathy: evidence-based clinical tools aspectsis presented and of assessment andoutcome then coupled and measures with essential and for advanced exam- management. J Orthop Sports Phys Therination. 2016;46(6):483-493. techniques. Special emphasis is placedCONCUSSION on examination of clinical evaluation and treatmentthe cervical of concussion.and thoracic spine as part of concussion assessment Advanced Concussion Management 32. Askling C, Tendvar M, Saartok T, Thorstenssonand treatment. A Sports Independent Study Course 28.1 9. Apply key examination and assessment methods for cervical/ releated hamstring strains: two cases with different etiologies Anne Mucha, PT, DPT, MS, NCS and injurythoracic sites. spine, Scand vestibular/oculomotorJ Med Sci SportsForLearning. Registration2000;10(5):304-307. Objectives system, and Fees, and visit exertion orthoptlearn.org CaraEditorial Troutman-Enseki, Staff PT, DPT, OCS, SCS following concussion. Additional1. Describe Questions—Call the signs, symptoms, tollbiomechanics, free 800/444-3982 and pathophys- Christopher Hughes, PT, PhD, OCS, CSCS—Editor 33. Askling C, Saartok T, Thorstensson A. Typeiology ofof a concussion.acute hamstring Tim Ryland,Gordon Riddle, PT, PT, EdD(c), DPT, ATC, OCS, MPT, SCS, OCS, CSCS—Associate CBIS Editor strain10. Appreciate affects flexibility, the role strength, of neurocognitive and2. time Cite keyto riskreturn testing factors forto sustaininginpre- concussion a concussion and indicators Sharon Klinski—Managing Editor leading to prolonged recovery following concussion. injuryevaluation level. Br J Sportsand management. Med. 2006;40(1):40-44.3. Describe common clinical profi les seen following concussion. ContinuingTopics and Authors Education Credit 11. Identify clinical profi les and 4. treatment Discuss the role strategies of biomarkers in forthe evaluation each and manage- The Basics of Concussion ment of concussion. FifteenAnne contact Mucha, PT, DPT, hours MS, NCS will be awarded to registrants concussion subtype: cervical,5. vestibular, Understand negative ocular, consequences mood, ofmi- poor concussion who Carasuccessfully Troutman-Enseki, complete PT, DPT, OCS, the SCS fi nal examination. graine, and cognitive/fatigue. management. 6. Describe important guidelines for return to play following The OrthopaedicPhysical Therapy Evaluation Section of Concussion pursues CEU approval from the 12. Describe important indicators forsport-related return concussion.to activity following followingAnne Mucha, states: PT, DPT, Nevada, MS, NCS Ohio, Oklahoma, California, 7. Discuss the advantages and disadvantages of various concus- Cara Troutman-Enseki, PT, DPT, OCS, SCS concussion. sion prevention strategies. and Texas.Tim Ryland, Registrants PT, EdD(c), MPT, OCS,from CBIS other states must apply 13. Discuss the role of sleep in 8.concussion Select evidence-based management, tools and outcome and measures for clinical evaluation and treatment of concussion. to theirAdvanced individual Concussion State Management Licensure Boards for PERFORMING ARTS PERFORMING employ interventionsPHYSICAL that can9. Apply be key used examination THERAPYto andmodify assessment sleep methods for cervical/ approvalAnne Mucha, of continuing PT, DPT, MS, NCS education credit. thoracic spine, vestibular/oculomotor system, and exertion Cara Troutman-Enseki, PT, DPT, OCS, SCS dysregulation. following concussion. Tim Ryland, PT, EdD(c), MPT, OCS, CBIS 14. Appreciate the inflMANAGEMENT uence of psychogenic10. Appreciate the factors role of neurocognitive in concussion testing in concussionOF Course content is not intended for use evaluation and management. Continuing Education Credit management. 11. Identify clinical profi les and treatment strategies for each by participantsFifteen contact hours outside will be awardedthe scope to registrants 15. Describe common pharmacologicconcussion and subtype: non-pharmacologic cervical, vestibular, ocular, mood, mi- who successfully complete the fi nal examination. CONCUSSIONgraine, and cognitive/fatigue. of theirThe Orthopaediclicense or Section regulation. pursues CEU approval from the treatment options for specifi c symptoms12. Describe important following indicators concussion. for return to activity following following states: Nevada, Ohio, Oklahoma, California, concussion.Independent Study Course 28.1 and Texas. Registrants from other states must apply 13. Discuss the role of sleep in concussion management, and to their individual State Licensure Boards for Description employ interventions that can be used to modify sleep approval of continuing education credit. Learning Objectives dysregulation. Editorial Staff This monograph series provides in-depth14. Appreciate coverage the infl uence offor psychogenic the eval- factors in concussion Course content is not intended for use 1. Describe the signs, symptoms, biomechanics,management. and pathophys- Christopher Hughes, PT, PhD, byOCS, participants CSCS—Editor outside the scope uation andiology treatment of a concussion. of concussion15. Describe by a physicalcommon pharmacologic therapist. andGordon Thenon-pharmacologic Riddle, PT, DPT, ATC, OCS,of their SCS, license CSCS—Associate or regulation. Editor authors2. are Cite recognizedkey risk factors for clinical sustaining experts a concussiontreatment in andthe options indicators fi eldfor specifi of cconcussion symptomsSharon following Klinski—Managing concussion. Editor leading to prolonged recovery following concussion. management.3. Describe The common basic clinical pathophysiology profi les seenDescription following underlying concussion. concussionTopics and Authors This monograph series provides in-depth coverage for the eval- 4. Discuss the role of biomarkers in the evaluation and manage- The Basics of Concussion is presented and then coupled withuation essential and treatment and of advanced concussion by aexam- physical therapist. The ment of concussion. ination techniques. Special emphasisauthors is are placed recognized on clinical examination experts inAnne the fi ofeld Mucha, of concussion PT, DPT, MS, NCS 5. Understand negative consequencesmanagement. of poor The concussion basic pathophysiology Cara underlying Troutman-Enseki, concussion PT, DPT, OCS, SCS the cervicalmanagement. and thoracic spine as ispart presented of concussionand then coupled with assessment essential and advanced exam- and treatment.6. Describe important guidelines forination return techniques. to play following Special emphasis is placedPhysical on examination Therapy Evaluationof of Concussion sport-related concussion. the cervical and thoracic spine as part of Anneconcussion Mucha, assessment PT, DPT, MS, NCS 7. Discuss the advantages and disadvantagesand treatment. of various concus- Cara Troutman-Enseki, PT, DPT, OCS, SCS sion prevention strategies. Tim Ryland, PT, EdD(c), MPT, OCS, CBIS For Registration8. Select evidence-based and and tools Fees, Fees, and For visitvisitoutcome Registration orthoptlearn.orgorthopt.org measures and for Fees, visit orthoptlearn.org clinical evaluation and treatment ofAdditional concussion. Questions—Call toll freeAdvanced 800/444-3982 Concussion Management Additional9. Apply key Questions—Call examinationQuestions–Call and assessment toll methodstoll free free for cervical/ 800/444-3982 800/444-3982Anne Mucha, PT, DPT, MS, NCS thoracic spine, vestibular/oculomotor system, and exertion Cara Troutman-Enseki, PT, DPT, OCS, SCS following concussion. Tim Ryland, PT, EdD(c), MPT, OCS, CBIS 10. Appreciate the role of neurocognitive testing in concussion Orthopaedic Practice volume 31 / number 1 / 2019 evaluation and management. 48Continuing Education Credit 11. Identify clinical profi les and treatment strategies for each Fifteen contact hours will be awarded to registrants concussion subtype: cervical, vestibular, ocular, mood, mi- who successfully complete the fi nal examination. graine, and cognitive/fatigue. The Orthopaedic Section pursues CEU approval from the 6938_OP_Jan.indd 48 12/17/18 12:55 PM 12. Describe important indicators for return to activity following following states: Nevada, Ohio, Oklahoma, California, concussion. and Texas. Registrants from other states must apply 13. Discuss the role of sleep in concussion management, and to their individual State Licensure Boards for employ interventions that can be used to modify sleep approval of continuing education credit. dysregulation. 14. Appreciate the infl uence of psychogenic factors in concussion Course content is not intended for use management. by participants outside the scope 15. Describe common pharmacologic and non-pharmacologic of their license or regulation. treatment options for specifi c symptoms following concussion.

Description This monograph series provides in-depth coverage for the evaluation and treatment of concussion by a physical therapist. The authors are recognized clinical experts in the ﬁ eld of concussion management. The basic pathophysiology underlying concussion is presented and then coupled with essential and advanced examination techniques. Special emphasis is placed on examination of the cervical and thoracic spine as part of concussion assessment and treatment.

For Registration and Fees, visit orthoptlearn.org Additional Questions—Call toll free 800/444-3982 This edition of Orthopedic Practice will be landing on your desk noninvasive interactive neurostimulation, and pulsed radio- right around the time of the Combined Sections Meeting 2019. frequency treatment for treating plantar fasciitis: A systematic This meeting always provides ample opportunity to catch up with review and network meta-analysis. Medicine (Baltimore). colleagues, invigorate practice with some new ideas, and stimulate 2018;97(43):e12819. our thinking with current evidence. Two talks in particular were 5. Franchini M, Cruciani M, Mengoli C, et al. Efficacy of interesting as the FASIG started planning for the meeting in early platelet-rich plasma as conservative treatment in orthopae- 2018. First, the FASIG sponsored the educational program titled, dics: a systematic review and meta-analysis. Blood Transfus. “A Foot Core Approach to Treating Plantar Fasciitis” by speakers 2018;16(6):502-513. Irene Davis, PT, PhD, FAPTA; Sarah Ridge, PhD; and Lindsay 6. Ling Y, Wang S. Effects of platelet-rich plasma in the treatment Wasserman, DPT, FAAOMPT. The second talk was titled “Physi- of plantar fasciitis: A meta-analysis of randomized controlled cal Therapist Management of Foot and Ankle Pain From Head to trials. Medicine (Baltimore). 2018;97(37):e12110. Toe,” by Ruth Chimenti, PT, DPT, PhD; Beth Fisher, PT, PhD, 7. Chan O, Malhotra K, Buraimoh O, et al. Gastrocnemius tight- FAPTA; and Mary Hastings, PT, DPT, ATC, MSCI. These two ness: A population based observational study. Foot Ankle Surg. talks offer some great insight into two very diverse, but historical 2018; pii: S1268-7731(18)30126-7. topics in foot and ankle care. Strengthening the foot has been a 8. Martin RL, Davenport TE, Reischl SF, et al. Heel pain- topic of debate for decades with seminal papers on muscle electro- plantar fasciitis: revision 2014. J Orthop Sports Phys Ther. myographic activity in the foot dating back to 1963.1 The focus on 2014;44(11):A1-33. foot strengthening continues today with novel work on midfoot 9. Mueller MJ, Maluf KS. Tissue adaptation to physical stress: a proposed "Physical Stress Theory" to guide physi-

power during walking and running which continues to define the FOOT& ANKLE paradigm for the role of foot strength.2,3 Equally historical and yet, cal therapist practice, education, and research. Phys Ther. also timely, is the discussion of pain pathology, impairments, and 2002;82(4):383-403. psychological factors. 10. Janwantanakul P, Sihawong R, Sitthipornvorakul E, Paksaichol The literature on management for plantar fasciitis over the past A. A path analysis of the effects of biopsychosocial factors on year has included systematic reviews on the use of laser therapy4 the onset of nonspecific low back pain in office workers. J Manipulative Physiol Ther and platelet-rich plasma,5,6 while insight into mechanisms that . 2018;41(5):405-412. might cause, or influence, plantar fasciitis such as gastrocnemius tightness7 and muscle strengthening are evolving. Clearly, our clinical practice guidelines have advocated the use of stretching and strengthening in the management of heel pain.8 Novel work, including that presented in regards to strengthening of the foot intrinsics, is sure to foster increased discussion and study on the topic of foot muscle strength in common foot conditions such as plantar fasciitis. It is also a FASIG highlight to see the topic of pain neurosci- ence focused on common foot and ankle conditions. The influence of tissue-specific stress on movement and pain is familiar in our biomechanical literature9 but has re-surfaced when compared and integrated into a biopsychosocial approach to pain.10 Finally, the consideration of brain-behavior effects on our patient instruction was wonderful to see integrated into case studies. I hope that you were either able to enjoy these talks at CSM personally, or will take a moment to review the slides posted online along with the supporting literature.

1. Basmajin J, Stecko G. The role of muscles in arch support of the foot. J Bone Joint Surg Am. 1963;45(6):1184-1190. 2. Bruening DA, Pohl MB, Takahashi KZ, Barrios JA. Midtarsal locking, the windlass mechanism, and running strike pattern: A kinematic and kinetic assessment. J Biomech. 2018;73:185-191. 3. DiLiberto FE, Nawoczenski DA, Houck J. Ankle and midfoot power during walking and stair ascent in healthy adults. J Appl Biomech. 2018;34(4):262-269. 4. Li X, Zhang L, Gu S, et al. Comparative effectiveness of extracorporeal shock wave, ultrasound, low-level laser therapy,

Orthopaedic Practice volume 31 / number 1 / 2019 49

6938_OP_Jan.indd 49 12/17/18 12:55 PM President’s Message with pain conditions and the frequently beneficial applications of stress reduction strategies, I have become curious about the under- Carolyn McManus, MPT, MA lying mechanisms that could explain my clinical observations. This article explores one proposed theory and its clinical implications. I The Pain SIG Board has been busy! We received approval from wish to thank Derrick Sueki, DPT, PhD, OCS, for his thoughtful the Academy of Physical Therapy Board to change our name to the review and suggestions prior to submission for publication. For Pain Special Interest Group. Thank you to all those who contrib- those with additional interest, Etienne Vachon-Presseau, PhD, uted time and energy to this process. from the Apkarian Lab at Northwestern University, and I will pres- Pain SIG Practice Chair, Craig Wassinger, PT, PhD, has been ent on this topic at NEXT 2019 in Chicago this coming June. actively involved in the development of the Clinical Practice Guideline (CPG) for Patient Education/Counseling to Treat Pain. The CPG team is currently working on the second phase of manu- Chronic Stress, Chronic Pain, and script reviews. Nearly 15,000 manuscripts were initially reviewed the Corticolimbic System and approximately 1500 selected for full text review. Over the next Carolyn McManus, MPT, MA few months the team will extract relevant data and initiate the CPG writing process. Their goal is to have a manuscript published The contribution of adverse stress and psychological distress in late 2019 or 2020 and corresponding presentations at various to persistent pain and disability has been proposed to impact a scientific meetings in a similar timeframe. range of pain conditions. Multiple studies have begun to suggest In addition, Craig is a member of a newly formed APTA the role of adverse stress on pain and disability.1-8 In a prospective workgroup that aims to provide PT information and pain-related multicenter study of individuals who presented to the emergency resources to patients, clinicians, and payors. Representatives from department within 24 hours of motor vehicle collision, helpless- APTA Academies and Sections were invited to participate in his ness and anger were associated with initial axial pain severity while workgroup, coordinated by Hadiya Guerrero, DPT. The Pain SIG hyperarousal symptoms most influenced and partially mediated Board will keep members appraised of the workgroup’s activities axial pain persistence in initial months post-collision.1 In a com- and provide members with the information and resources devel- munity sample of older adults, higher scores on the Perceived Stress oped by the workgroup as they become available. Scale were associated with greater pain intensity and interference.2 Pain SIG Public Relations Chair, Derrick Sueki, DPT, PhD,

PAIN In a study of women undergoing surgery for primary breast cancer, OCS, has spoken at the national, state, and local levels about the preoperative distress was significantly associated with moderate to need to promote physical therapists as pain specialists and as such severe persistent pain at 8 months.3 In a cohort of patients pre- has advocated for physical therapy as the first treatment choice senting to a shoulder clinic, catastrophic thinking and decreased for people who have pain. While realizing that public and profes- self-efficacyere w shown to be associated with greater shoulder pain sional awareness is an important aspect in changing practice pat- and perceived disability.4 In addition, more severe stress symptoms terns, it is also important to identify clinicians who possess the skill was one of 3 factors predictive of activity limitation after 2 years in set to treat patients with various types of pain. In this regard the women with chronic low back pain in a primary health care set- Pain SIG, with the consent of the AOPT Board of Directors, has ting.5 It is also important to note, the relationship between psycho- actively begun to take the steps necessary to explore the feasibility social distress and disability in patients with pain is not universal.9 of a developing a Specialization Tract focused on the science and management of pain. If established, the Pain Specialty Certifica- THE CORTICOLIMBIC SYSTEM tion would not only provide physical therapists with a means of While evidence from clinical studies indicates a possible link demonstrating their advanced knowledge in the field of pain but between stress and pain, in recent years, research has also begun to would also provide the public and health care professionals with offer insight into the cortical and subcortical mechanisms involved a means of identifying those physical therapists who specialize in in this association. By examining regions of the brain in processing the treatment of pain. This process is in its infancy and there are both stress and pain, clinicians can begin to consider how psy- a number of steps needed to bring this to fruition. Stay tuned for chological stress and difficult life circumstances could influence a more information as our efforts go forward. patient’s symptoms and function. In addition, the unpredictable Education Chair, Mark Shepherd, DPT, OCS, is coordinating and uncontrollable features of persistent pain could contribute to the Pain SIG quarterly webinar series, Current Topic in Pain. Keep an ongoing stress reaction and this, too, could potentially become an eye out for information on this series that will launch in 2019. an influencing factor in a patient’s presentation.10 This quarter, I have written an article on the topic of chronic A substantial body of research has consistently demonstrated stress, chronic pain, and the corticolimbic system. When I began that the corticolimbic system is involved in the initiation, regula- practicing physical therapy in an outpatient orthopaedic clinic in tion, and termination of the stress reaction.11,12 Key brain regions the 1980s, I observed that patients who appeared highly stressed of the corticolimbic system include the prefrontal cortex (PFC), often had a slower and more complex recovery course than those amygdala, and hippocampus. These brain areas are interconnected who did not appear stressed. This sparked a career-long interest in and influence each other through both direct and indirect neural this topic. As I continue to observe the impact of stress on patients

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6938_OP_Jan.indd 50 12/17/18 12:55 PM pathways.11 While acute stress can elicit an adaptive physiologi- sistently identify increases in activity in the amygdala in models of cal reaction that promotes survival, chronic stress can contribute arthritic and neuropathic pain.23 In humans, arthritic pain has been to a dysregulation of the hypothalamic-pituitary-adrenal axis and shown to be associated with increased activity in the amygdala.28 disrupt the homeostasis of an organism.10 When stress becomes As patients with subacute back pain transition to chronic pain, the chronic, the PFC, amygdala and hippocampus also show maladap- amygdala has been shown to demonstrate increased responsiveness tive neuroplastic changes and altered brain activity that impacts the to spontaneous pain episodes.29 In migraine patients, altered func- down-regulation stress reaction.11,12 Similar neuroplastic changes tional connectivity of the amygdala has been identified.30 are present in some chronic pain conditions, leading to the propo- sition of a theoretical model for the role of stress-associated corti- THE HIPPOCAMPUS colimbic changes in the generation of chronic pain.10,13 Below is a The hippocampus is involved in regulating stress hormones summary of stress and pain-related changes in the PFC, amygdala through the HPA axis, fear learning, and memory.31,32 Corticoste- and hippocampus. They suggest a possible role for stress-associated roid receptors are abundant in the hippocampus and evidence from corticolimbic changes in chronic pain conditions. rodent studies suggests increases in glucocorticoid levels, induced by chronic stress, inhibit new neuron formation and cell prolif- THE PREFRONTAL CORTEX eration in the hippocampus.31 In addition, smaller hippocampal The PFC functions to generate the highest order cognitive abil- volume has been identified in subjects with PTSD.32 Older adults ities, including abstract thought, flexible goal-directed behavior, with significantly prolonged cortisol elevation were shown to have and the regulation of emotions.12 Acute stress-related changes in reduced hippocampal volume compared with normal cortisol con- the PFC have been observed in both rodent and human studies. trols and the degree of hippocampal atrophy correlated strongly Rodent studies suggest stress-associated release of catecholamines with the degree of cortisol elevation.33 results in reduced neuronal firing in the PFC while simultaneously Evidence from both rodent and human studies identify pain- promoting an increase in activity in the amygdala.12 This shift in related changes in the hippocampus. Decreases in neurogenesis in neuronal activity contributes to the transfer of brain processing the hippocampus in rodents subject to a neuropathic pain proce- from a reflective control to a more habitual, reflexive regulation dure were shown to be greater in a subset of animals also subject to of behavior.12,14 Chronic exposure to stress has been shown to a daily stressor.34 Patients with chronic back pain have been shown contribute to additional structural changes in the PFC, including to have smaller hippocampal volume and higher levels of corti- reductions in dendrite length, branching, and spine density.12 These sol than control subjects.35,36 Fibromyalgia patients demonstrate changes reinforce neurocircuitry that promotes a more primitive, reduced hippocampal volume compared with healthy controls.37 12,14

habitual behavior over a slower, reflective one. In human stud- In addition, hippocampal morphology and functional changes in PAIN ies, chronic stress has been shown to impair attentional control, people with migraine have been identified and related to headache disrupt PFC functional connectivity, and impair the PFC regula- frequency, accumulative number of migraines, anxiety, and depres- tion of the amygdala.15,16 The number of adverse events a person sion scores and genetic variants.38 has experienced and increased perception of stress have both been Together, these changes in cortical and subcortical activity asso- found to be related to decreased PFC volumes.17,18 ciated with chronic stress and chronic pain suggest a relationship Prefrontal cortex changes have been found in patients with between the two conditions. While this relationship is merely cor- chronic pain. Patients with chronic back pain demonstrate regional relational and not causative, it invites consideration of the role of gray matter volume decreases in the PFC.19,20 Atrophy of the ven- chronic adverse stress and psychological distress in chronic pain tromedial PFC gray matter is found in patients with complex and the potential application of stress reduction strategies to regional pain syndrome.21 Also, patients with fibromyalgia have chronic pain treatment. been shown to have significantly less gray matter density in the medial prefrontal cortex and 3.3 times the age-related loss in total CLINICAL IMPLICATIONS gray matter volume compared to healthy controls.22 In addition, Based on evidence suggesting increases in adverse stress and impaired prefrontal cortical function has been proposed to con- psychological distress can be associated with increases in pain and tribute to the amplification of amygdala-driven pain mechanisms.23 disability, the question becomes whether treatment strategies that reduce stress could reduce pain and disability. Such strategies could THE AMYGDALA include those that mitigate the experience of distress; fear and anxi- The amygdala plays a central role in emotional responses ety; and/or promote relaxation, positive mood, and self-efficacy. and affective states and has also been identified as a brain region Although additional research is warranted, 3 lines of evidence show involved in the emotional-affective dimension of pain and in pain clinical promise: modulation.23 Chronic stress is associated with amygdala hyper- 1. Exercise: Physical activity and exercise as an intervention excitability and structural plasticity in rodents.24,25 Neuroplas- for patients with chronic pain has been shown to improve tic changes observed in rodents under chronic stress conditions pain severity and physical function, and consequent qual- include dendritic hypertrophy and increases in spine density.25 In ity of life.40 Regular exercise has also been shown to prevent addition, chronic stress dysregulates amygdala output to the pre- or ameliorate metabolic and psychological disturbances in- frontal cortex, providing a mechanism by which chronic stress can duced by chronic stress.41 In addition, voluntary running has lead to increased anxiety.26 In humans, neuroimaging studies have been found to enhance hippocampal neurogenesis in mice.42 demonstrated that patients with post-traumatic stress disorder In older adults, aerobic exercise has been shown to increase (PTSD) have greater amygdala responsivity compared to controls.27 the size of the hippocampus in comparison to control condi- Increased amygdala activity is documented in both rodent and tions.43 human pain studies. Electrophysiological studies in animals con-

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6938_OP_Jan.indd 51 12/17/18 12:55 PM 2. Mindfulness: Mindfulness training has been found to reduce Predictors of future activity limitation in women with chronic pain in chronic pain conditions.44,45 Mindfulness training has low back pain consulting primary care: a 2-year prospective also been shown to decrease physiological markers of stress longitudinal cohort study. BMJ Open. 2017;7(6):e013974. in a range of populations.46 In addition, a systematic review 6. Smedbraten K, Oiestad BE, Roe Y. Emotional distress was of brain changes in stressed, anxious, and healthy adults who associated with persistent shoulder pain after physiotherapy: participated in mindfulness training identified increases in a prospective cohort study. BMC Musculoskelet Disord. activity, connectivity, and volume in the PFC and hippocam- 2018;19(1):304. pus and decreases in activity in the amygdala.47 7. Randall ET, Smith KR, Kronman CA, Conroy C, Smith AM, 3. Social Support: In the laboratory setting, social support has Simons LE. Feeling the pressure to be perfect: effect on pain- been shown to attenuate physiological stress responses and related distress and dysfunction in youth with chronic pain. J experimental pain sensitivity.48 In a study of older adults, me- Pain. 2018;19(4):418-429. dial PFC thickness was found to be positively correlated with 8. Ross C, Juraskova I, Lee H, et al. Psychological distress medi- social support while amygdala volume was negatively associates the relationship between pain and disability in hand or ated with social support and positively related to stress.49 wrist fractures. J Pain. 2015;16(9):836-843. Other therapeutic interventions that may be of benefit in 9. Preuper HR, Boonstra AM, Wever D, et al. Differences in the reducing a patient’s stress reaction include pain science education, relationship between psychosocial distress and self-reported breathing exercises, progressive muscle relaxation, guided imag- disability in patients with chronic low back in six reha- ery, and engagement in positive activities.50–55 Further research is bilitation centers in the Netherlands. Spine (Phila Pa 1976). needed to examine the effects of these interventions on pain, stress 2011;36(12):969-976. measures, and corticolimbic activity. 10. Vachon-Presseau E. Effects of stress on the corticolimbic system: implications for chronic pain. Prog Neuropsychopharma- SUMMARY col Biol Psychiatry. 2018;87(Pt B):216-223. While chronic pain is a multifaceted and highly complex con- 11. McEwen BS, Morrison JH. The brain on stress: vulnerability dition with no single cause or one-size-fits-all treatment, evidence and plasticity of the prefrontal cortex over the life course. suggests adverse stress and psychological distress may play a role in Neuron. 2013;79(1):16-29. persistent pain and disability. In addition, chronic stress is associ- 12. Arnsten AF. Stress weakens prefrontal networks: ated with neuroplastic changes in the corticolimbic system, a brain molecular insults to higher cognition. Nat Neurosci. region that also demonstrates changes in chronic pain conditions. 2015;18(10):1376-1385. An innovative theoretical model has been proposed that suggests 13. Abdallah CG, Geha P. Chronic pain and chronic stress: Two maladaptive neuroplastic changes in the corticolimbic system asso- sides of the same coin? Chronic Stress (Thousands Oaks). 2017;1. ciated with chronic stress may play a role in brain changes observed 14. Arnsten AF, Raskind MA, Taylor FB, Connor DF. The effects in chronic pain conditions. This would imply treatment strategies of stress exposure on prefrontal cortex: translating basic research into successful treatments for post-traumatic stress disorder. PAIN that contribute to a reduction in the stress reaction could potentially benefit patients with chronic pain. These treatment strategies Neurobiol Stress. 2015;1:89-99. include aerobic exercise, mindfulness training, and encouraging 15. Liston C, McEwen BS, Casey BJ. Psychosocial stress reversibly social activities that would enhance a patient’s social support, as disrupts prefrontal processing and attentional control. Proc Natl well as pain science education, breathing exercises, progressive Acad Sci U S A. 2009;106(3):912-917. muscle relaxation, guided imagery, and engagement in positive 16. Kim P, Evans GW, Angstadt M, et al. Effects of child- activities. This proposed theoretical model and the role of sug- hood poverty and chronic stress on emotion regulatory gested treatment strategies on stress measures and corticolimbic brain function in adulthood. Proc Natl Acad Sci U S A. activity warrant further research. 2013;110(46):18442-18447. 17. Ansell EB, Rando K, Tuit K, Guarnaccia J, Sinha R. Cumu- REFERENCES lative adversity and smaller gray matter volume in medial 1. Feinberg RK, Hu J, Weaver MA, et al. Stress-related psycho- prefrontal, anterior cingulate, and insula regions. Biol Psychia- logical symptoms contribute to axial pain persistence after try. 2012;72(1):57-64. motor vehicle collision: path analysis results from a prospective 18. Moreno GL, Bruss J, Denburg NL. Increased perceived stress longitudinal study. Pain. 2017;158(4):682-690. is related to decreased prefrontal cortex volumes among older 2. White RS, Jiang J, Hall CB, et al. Higher perceived stress adults. J Clin Exp Neuropsychol. 2017;39(4):313-325. scale scores are associated with higher pain intensity and 19. Yuan C, Shi H, Pan P, et al. Gray matter abnormalities associ- pain interference levels in older adults. J Am Geriatr Soc. ated with chronic back pain: a meta-analysis of voxel-based 2014;62(12):2350-2356. morphometric studies. Clin J Pain. 2017;33(11):983-990. 3. Mejdahl MK, Mertz BG, Bidstrup PE, Andersen KG. Pre- 20. Fritz HC, McAuley JH, Wittfeld K, et al. Chronic back pain is operative distress predicts persistent pain after breast cancer associated with decreased prefrontal and anterior insular gray treatment: a prospective cohort study. J Natl Compr Cancr matter: results from a population-based cohort study. J Pain. Netw. 2015;13(8):995-1003. 2016;17(1):111-118. 4. Menendez ME, Baker DK, Oladeji LO, Fryberger CT, 21. Geha PY, Baliki MN, Harden RN, Bauer WR, Parrish TB, McGwin G, Ponce BA. Psychological distress is associated with Apkarian AV. The brain in chronic CRPS pain: abnormal gray- greater perceived disability and pain in patients presenting to a white matter interactions in emotional and autonomic regions. shoulder clinic. J Bone Joint Surg Am. 2015;97(24):1999-2003. Neuron. 2008;60(4):570-581. 5. Nordeman L, Thorselius L, Gunnarsson R, Mannerkorpi K. 22. Kuchinad A, Schweinhardt P, Seminowicz DA, Wood PB, Chizh BA, Bushnell MC. Accelerated brain gray matter loss in

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6938_OP_Jan.indd 52 12/17/18 12:55 PM fibromyalgia patients: premature aging of the brain? J Neurosci. stress system dysregulation and comorbidities. Ann N Y Acad 2007;27(15):4004-4007. Sci. 2006;1083:196-213. 23. Neugebauer V. Amygdala pain mechanisms. Handb Exp Phar- 42. Van Praag, H, Christie RC, Sejnowski TJ, Gage FH. Running macol. 2015;227:261-284. enhances neurogenesis, learning, and long-term potentiation in 24. Rosenkranz JA, Venheim ER Padival M. Chronic stress mice. Proc Natl Acad Sci U S A. 1999;96(23):13427-13431. causes amygdala hyperexcitability in rodents. Biol Psychiatry. 43. Erickson Kl, Voss MW, Prakash RS, et al. Exercise training 2010;67(12):1128-1136. increases size of hippocampus and improves memory. Proc Natl 25. Zhang JY, Liu TH, He Y, et al. Chronic stress remodels syn- Acad Sci U S A. 2011;108(7):3017-3022. apses in an amygdala circuit-specific manner. Biol Psychiatry. 44. Veehof MN, Trompetter HR, Bohlmeijer ET, Schruers KM. 2018. pii: S0006-3223(18)31633-0. Acceptance and mindfulness-based interventions for the treat- 26. Lowery-Gionta EG, Crowey NA, Bukalo O, Silverstein ment of chronic pain: a meta-analytic review. Cogn Behav Ther. S, Holmes A, Kash TL. Chronic stress dysregulates amyg- 2016;45(1):5-31. dalar output to the prefrontal cortex. Neuropharmacology. 45. Hilton L, Hempel S, Ewing BA, et al. Mindfulness meditation 2018;139:68-75. for chronic pain: Systematic review and meta-analysis. Ann 27. Shin LM, Liberzon I. The neurocircuitry of fear, stress and anx- Behav Med. 2017;51(2):199-213. iety disorders. Neuropsychopharmacology. 2010;35(1):169-191. 46. Pascoe MC, Thompson DR, Jenkins ZM, Ski CF. Mindfulness 28. Kulkarni B, Bentley DE, Elliott R, et al. Arthritic pain is mediates physiological markers of stress: systematic review and processed in brain areas concerned with emotions and fear. meta-analysis. J Psychiatr Res. 2017;95:156-178. Arthritis Rheum. 2007;56(4):1345-1354. 47. Gotink RA, Meijboom R, Vernooij, Smits M, Hunink MG. 29. Hashmi JA, Baliki MN, Huang I, et al. Shape shifting 8-week Mindfulness Based Stress Reduction induces brain pain: chronification of back pain shifts brain representation changes similar to traditional long-term meditation practice – a from nociceptive to emotional circuits. Brain. 2013;136(Pt systematic review. Brain Cogn. 2016;108:32-41. 9):2751-2768. 48. Roberts MH, Klatzkin RR, Mechlin B. Social support 30. Chen Z, Chen X, Liu M, Dong Z, Ma L, Yu S. Altered attenuates physiological stress responses and experimen- functional connectivity of amygdala underlying the neu- tal pain sensitivity to cold pressor pain. Ann Behav Med. romechanism of migraine pathogenesis. J Headache Pain. 2015;49(4):557-569. 2017;18(1):7. 49. Sherman SM, Cheng YP, Fingerman KL, Schnyer DM. Social 31. Mirescu C, Gould E. Stress and adult neurogenesis. Hippocam- support, stress and the aging brain. Soc Cogn Affect Neurosci. pus. 2006;16(3):233-238. 2016;11(7):1050-1058. 32. Logue MW, van Rooij SJH, Dennis EL, et al. Smaller hip- 50. Moseley GL, Butler DS. Fifteen years of explaining pain: the PAIN pocampal volume in posttraumatic stress disorder: a multisite past, present and future. J Pain. 2015;16(9):807-813. ENIGMA-PGC study: subcortical volumetry results from 51. Steffen PR, Austin T, DeBarros A, Brown T. The impact of posttraumatic stress disorder consortia. Biol Psychiatry. resonance frequency breathing on measures of heart rate 2018;83(3):244-253. variability, blood pressure and mood. Front Public Health. 33. Lupien SJ, de Leon M, de Santi S, et al. Cortisol levels during 2017;5:222. human aging predict hippocampal atrophy and memory defi- 52. Anderson BE, Bliven KCH. The use of breathing exercises in cits. Nat Neurosci. 1998;1:69-73. the treatment of chronic, nonspecific low back pain. J Sport 34. Romero-Grimaldi C, Berrocoso E, Alba-Delgado C, et al. Stress Rehabil. 2017;26(5):452-458. increases the negative effects of chronic pain on hippocampal 53. Baird C, Sands L. A pilot study of the effectiveness of guided neurogenesis. Anesth Analg. 2015;121(4):1078-1088. imagery with progressive muscle relaxation to reduce chronic 35. Mutso AA, Radzicki D, Baliki MN, et al. Abnormalities in pain and mobility difficulties of osteoarthritis. Pain Manag hippocampal functioning with persistent pain. J Neurosci. Nurs. 2004;5(3):97-104. 2012;32(17):5747-5756. 54. Muller R, Gertz KJ, Molton IR, et al. Effects of a tailored 36. Vachon-Preasseau E, Roy M, Martel MO, et al. The stress positive psychology intervention on well-being and pain in model of chronic pain: evidence from basal cortisol and individuals with chronic pain and physical disability: a feasibil- hippocampal structure and function in humans. Brain. ity trial. Clin J Pain. 2016;32(1):32-44. 2013;136(Pt3):815-827. 55. Hanssen MM, Peters ML, Boselie JJ, Meulders A. Can positive 37. McCrae CS, O’Shea AM, Boissoneault J, et al. Fibromyalgia affect attenuate (persistent) pain? State of the art and clinical patients have reduced hippocampal volume compared with implications. Curr Rheumatol Rep. 2017;19(12):80. healthy controls. J Pain Res. 2015;8:47-52. 38. Lui HY, Ghou KH, Chen WT. Migraine and the hippocampus. Curr Pain Headache Rep. 2018;22(2):13. 39. Seminowicz DA, Shpaner M, Keaser ML, et al. Cognitive- behavioral therapy increases prefrontal cortex gray matter in patients with chronic pain. J Pain. 2013;14(12):1573-1584. 40. Geneen LJ, Moore RA, Clarke C, Martin D, Colvin LA, Smith BH. Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews. Cochrane Database Syst Rev. 2017;4:CD011279. 41. Tsatsoulis A, Fountoulakis S. The protective role of exercise on

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6938_OP_Jan.indd 53 12/17/18 12:55 PM EXPANSION OF PUBLISHED LITERATURE RELATED TO LEGISLATIVE ACTIVITY PHYSICAL THERAPISTS AND IMAGING If there is an effort toward changing the scope of practice to Several manuscripts are in development subsequent to research include referral for imaging in your jurisdiction, please let us know. having been completed and still on-going relating to physical thera- Word of these efforts sometimes travels slowly. pists and referral for imaging or the use of ultrasound imaging. By the time this OPTP appears in your mailbox, some may have been IMAGING SIG MEETINGS & COMMUNICATION published and others are definitely forthcoming. One project we In addition to our live member meetings at Combined Sections will be tackling in the future is a running reference list on the Imag- Meeting, the Imaging SIG will conduct at least one web-based ing SIG webpage. The logistics of this are still being worked out, meeting in the year. These are usually announced 3 to 4 weeks in but we want a readily accessible list of references for those inter- advance by email and through our social media outlets. If you are ested in this topic. Likewise, if you have just such a publication or unable to attend those while being held real time, recordings of a manuscript that has been accepted, please let us know so we can those meetings are available on our webpage on the Academy of add it to the list. Orthopaedic Physical Therapy’s website. Other forms of communication include occasional emails to REIMBURSEMENT all Imaging SIG members, our social media, and this publication. With referral for imaging privileges gradually expanding, we are Please remember to save @orthopt.org among the safe domains in incrementally achieving one of the primary objectives of the Imag- your email program. ing SIG. That success on the legal scope of practice front, however, does not guarantee our success in another critical area: reimbursePHYSICAL- IMAGING SIGTHERAPY WEBPAGE ment. With physical therapist use of both ultrasound imaging to Please remember to occasionally visit the Imaging SIG’s web- complement clinical examinations and referral for other formsMANAGEMENT of page for information and resources. OF This is the direct link: https:// imaging toward patient management, we are not guaranteed that www.orthopt.org/content/special-interest-groups/imaging reimbursement for those services for the patient by third-party CONCUSSIONYou can alternately find this by going to the Academy for Ortho- payers will occur. There appears to be significant variability across paedic PhysicalIndependent Therapy’s Study Course website 28.1 and selecting from the “Special locations and plans in whether reimbursement occurs or not. Interest Group” page. The Imaging SIG will be forming a task forceLearning to address Objectives this. Becoming a SIG memberEditorial is Staff not an additional cost beyond being 1. Describe the signs, symptoms, biomechanics, and pathophys- Christopher Hughes, PT, PhD, OCS, CSCS—Editor Clearly, this barrier must change for the expansion ofiology imaging of a concussion. privi- a member of the Academy.Gordon You Riddle, simply PT, DPT, ATC, ask OCS, to SCS, be CSCS—Associate added as a Editor member 2. Cite key risk factors for sustaining a concussion and indicators Sharon Klinski—Managing Editor leges to be successful. If you have an interest in this arealeading and to prolonged partic recovery- followingby selecting concussion. the “Become an I-SIG Member” item on the webpage. 3. Describe common clinical profi les seen following concussion. Topics and Authors IMAGING ularly if you have personal experience in this area, please contact us. Contacting the Imaging SIG officers, as suggested multiple 4. Discuss the role of biomarkers in the evaluation and manage- The Basics of Concussion ment of concussion. times on this page, canAnne be Mucha, done PT, DPT, through MS, NCS that page or by simply 5. Understand negative consequences of poor concussion Cara Troutman-Enseki, PT, DPT, OCS, SCS STRATEGIC PLAN management. contacting the President at [email protected] (6th character is a We continue to work in research, education, and6. Describe practice important in our guidelines forlower return tocase play letterfollowing “L” followedPhysical Therapy by two Evaluation zeros). of Concussion sport-related concussion. Anne Mucha, PT, DPT, MS, NCS strategic plan. This plan was formulated and initiated7. Discuss CLINICAL3 the years advantages ago. and disadvantages of various concus- IMAGINGCara Troutman-Enseki, PT, DPT, OCS, SCS In the coming months, we will be revisiting this plansion for prevention your strategiesinput . Tim Ryland, PT, EdD(c), MPT, OCS, CBIS 8. Select evidence-based tools and outcome measures forIndependent Study Course 27.3 and for areas of particular emphasis that you see as clinicalimportant. evaluation and Of treatment of concussion.CLINICALAdvanced Concussion IMAGING Management 9. Apply key examination and assessment methods for cervical/ Anne Mucha, PT, DPT, MS, NCS course, we want your participation in this process,thoracic particularly spine, vestibular/oculomotor if system, and exertion Cara Troutman-Enseki,Independent PT, DPT, OCS, Study SCS Course 27.3 following concussion. Tim Ryland, PT, EdD(c), MPT, OCS, CBIS you have knowledgeLearning or experience Objectives in those related10. focus Appreciate areas. the role of neurocognitiveDescription testing in concussion 1. Describe the importance of having physicalevaluation therapists and management. is monograph series coversContinuing an introduction Education to the Creditbasic 11. Identify clinical profi les and treatment strategies for each study imaging. principles underlying the scienceFifteen andcontact diagnostic hours will utilitybe awarded of to registrants ULTRASOUND WEBINARS IN ASSOCIATIONconcussion WITH subtype: cervical, vestibular, ocular, mood, mi- who successfully complete the fi nal examination. 2. Identify relevant anatomy on diagnostic images.graine, and cognitive/fatigue. imaging for the physical therapist.The Orthopaedic e fi rst Section monograph pursues CEU is aapproval from the AIUM 3. Defi ne the diff erent types of musculoskeletal12. Describe imaging important and indicators for returnprimer to activity that following discusses principlesfollowing of conventional states: Nevada, Ohio,plain Oklahoma, fi lm California, the distinguishing information gathered fromconcussion. each. radiographs (x-rays); computedand Texas. tomography Registrants (CT) from other scans, states must apply We are still looking for additional suggestions for13. Discuss physical the role thera of sleep- in concussion management, and 4. Understand basic radiographic terminology and the basic magnetic resonance imaging,to theirultrasound individual imaging; State Licensure diagnostic Boards for pist led webinars to be done with the American Instituteemploy interventionsfor Ultra that- can be used to modify sleep approval of continuing education credit. principles of radiography. dysregulation. ultrasound and rehabilitative ultrasound imaging; and nuclear sound in Medicine.5. Over Discuss the factors past that two infl uenceyears, resolution, they14. have Appreciate quality, sought and the infl uenceour of psychogenicimaging. factors in concussion e second and thirdCourse monographs content is not coverintended imaging for use for interpretation of imaging. management. the extremities and spine andby participantsits role in outsidethe evaluation the scope of select input into their educational programming. If you15. have Describe suggestions common pharmacologic and non-pharmacologic 6. Discuss basic viewing strategies for plain fi lm, computed musculoskeletal injuries. Applicationof their license of or the regulation. material is for future webinars—both by topic and/or by presenter,treatment please options forpass specifi c symptoms following concussion. tomography, and magnetic resonance images. enhanced through the presentation of case studies. on your suggestions7. to Discuss us. diff erences among and indicationsDescription for various Remember that justimaging two methods short and years modalities. ago, AIUMThis monograph did not series rec provides- in-depthContinuing coverage for the eval- Education Credit 8. Understand the clinical decision makinguation model and treatment for of concussion by a physical therapist. The authors are recognized clinical experts inFifteen the fi eld ofcontact concussion hours will be awarded to registrants who suc- ognize physical therapistsdetermining in imagetheir sequence training using manuals American Collegeand ofother For Registration and Fees, management. The basic pathophysiologycessfully underlying complete concussion the fi nal examination. e Orthopaedic Sec- official documents.Radiology-ow, N theyAppropriateness ask us to helpCriteria in and istheir presented other educational clinical and then coupled with essential and advanced exam- visittion pursues orthopt.org CEU approval from the following states: Nevada, prediction rules. ination techniques. Special emphasis is placed on examination of programming. Ohio, Oklahoma, California, and Texas. Registrants from other 9. Understand the use of evidence-basedthe guidelines cervical and for thoracic spine as part of concussion assessment and treatment. states must apply to their individual State Licensure Boards for Those webinars applicationremain ofavailable imaging modalities for free for musculoskeletalviewing by going Additional Questions– approval of continuing education credit. through the website aium.orgdisorders of theor extremities.by going to YouTube and finding Call toll free For Registration and Fees, visit orthoptlearn.org 10. Discuss the imaging fi ndings for musculoskeletal disorders 800/444-3982 AIUM’s channel by simply searching for “AIUMAdditional webinar Questions—Call series.” toll freeCourse 800/444-3982 content is not intended for use by participants outside of the spine and extremities in the context of clinical the scope of their license or regulation. This is great continuingpresentations education of patients. at no cost. 11. Identify signs and symptoms of red fl ags and specifi c causes of spine pain that require emergent referral and/or Editorial Staff immediate imaging. 54 Christopher Hughes, PT, PhD, OCS, CSCS—Editor Orthopaedic Practice volume 31 / number 1 / 2019 12. Appropriately refer patients with acute and chronic spinal Gordon Riddle, PT, DPT, ATC, OCS, SCS, CSCS—Associate Editor disorders for diagnostic imaging based on clinical practice Sharon Klinski—Managing Editor guidelines. 6938_OP_Jan.indd 54 13. Synthesize available patient examination fi ndings with 12/17/18 12:55 PM imaging evidence to develop more eff ective intervention strategies.

Topics and Authors Basic Diagnostic Imaging Principles Ira Gorman, PT, PhD Imaging of the Extremities Deepak Kumar, PT, PhD, OCS Amee L. Seitz, PT, PhD, DPT, OCS Spinal Imaging: Update for the Treating Physical erapist J. Megan Sions, DPT, PhD, OCS James Elliott, PT, PhD George J. Beneck, PT, PhD, OCS, KEMG Charles Hazle, PT, PhD

For Registration and Fees, visit orthoptlearn.org Additional Questions—Call toll free 800/444-3982 ORFSIG Members, NATIONAL STUDENT CONCLAVE As 2018 comes to an end, it is important to reflect on the year I had the pleasure of joining Rosie Canizares, VP of the Per- and see what all we have accomplished. forming Arts SIG in attending National Student Conclave. We Here is a recap of 2018! had several aspiring resident/fellows stop by the booth and say hello. The first 50 people received a free ORFSIG Shaker bottle, STRATEGIC PLANNING which was a huge hit! Thanks to Mary Derrick, Nominating Com- Thank you to Janet Bezner and our strategic planning members mittee member, we were able to hand out a “Frequently Asked for your time in developing our new strategic plan. We look for- Questions” handout on why and how one should choose a resi- ward to implementing our Vision and Mission in 2019! dency or fellowship suited for them. It was great meeting with such ORTHOPAEDIC RESIDENCY/FELLOWSHIP young aspiring individuals. VISION: The National Student Conclave also held the first ABPTRFE To be a community of excellence in orthopaedic residency and Residency and Fellowship Reception from previously being hosted fellowship education. at CSM. We will continue to investigate the options for programs to meet with prospective residents and fellows. MISSION: Serve and support the orthopaedic residency and fellowship community. A special thank you to those members who have devoted their time and talent in the strategic planning process. Board Liaison: Members: Aimee Klein Chris Gaines Practice Committee Chair: Chrysta Lloyd Kathy Cieslak Darren Calley Residency and Fellowship: Megan Frazee Molly Malloy Kirk Bentzen Academy Office Staff: Kris Porter Tara Fredrickson Matthew Thomason ORFSIG Leadership: Mary Kate McDonnell VP/Education Chair: Sarah Nonaka Kathleen Geist Stephen Kareha Nominating Committee: Chair: Matt Stark Mary Derrick Melissa Dreger

ORFSIG STRUCTURE WITHIN THE ACADEMY OF ORTHOPAEDIC PHYSICAL THERAPY (AOPT) Historically, residency and fellowship matters fell within the Practice Committee of AOPT. As we have developed there has Manning the booth at National Student Conclave: Rosie been a question as to what matters would be the responsibility Canizares, VP of the Performing Arts SIG and Matt Haberl, of the Practice Committee and that of the ORFSIG. After work- President of the ORFSIG. ing with our Board Liaison Aimee Klein, and Practice Committee Chair, Kathy Cieslak we now have a better understanding of how “MENTORING THE MENTOR” WEBINAR responsibilities will be separated. Moving forward: We co-hosted a free webinar regarding “Mentoring to Mentor.” • ORFSIG will be primary contact and resource for Orthopae- A HUGE thank you to Kris Porter, Arlene McCarthy, and Carol dic Residency and Fellowship related items. Jo Tischner for their tremendous work and time in presenting to a • ORFSIG will work with Board Liaison for direction and record number 72 attendees. communication to the Board. In 2019 we look forward to unveiling a new Annual Mentor • ORFSIG will provide recommendations to the ISC Editor Observation form to assist programs in taking their mentors from regarding R/F curriculum package. Work in conjunction good to GREAT! with Practice Committee. • Practice Committee will continue to oversee R/F grant pro- MEMBER SWAG gram (Academy funded grant). Mary Derrick and Matt Stark developed some great articles for our members to represent the ORFSIG. Make sure to come to the ORFSIG business meeting at CSM or swing by the

Orthopaedic Practice volume 31 / number 1 / 2019 55

6938_OP_Jan.indd 55 12/17/18 12:55 PM Academy of Orthopaedic Physical Therapy’s booth to check out a work group lead by Peter McMenamin, Tom Denninger, Kevin these great items. Farrell, Joe Donnelly, and Stephan Kareha to evaluate low resident application volumes and potential reporting measures that may affect the data. Several questions remain regarding the current aggregate data where we hope to gain clarity: • Are there regional shortages/surpluses? • Does model matter? Are current prospects choosing a specific model (Hospital, University, Private Practice, Hybrid, etc.) / specific models suffering? • Is the demographic of residents/fellows changing? • Is our production of residency/fellowships in line with our market prospective res/fellows?

STANDARDIZED OFFER DATE PROGRAM SURVEY Given some of the struggles from programs filling residency positions and feedback from clinical sites regarding multiple resident interviews in their final internship, the question of a standard offer date was proposed. To better understand this Stephan Kareha, Misha Bradford, Aaron Keil, and Eric Magrum sent out a survey to all orthopaedic residency and fellowship directors. Seventy nine programs responded to date with the majority of programs (54%) not interested in a common offer date. A more detailed breakdown of the survey will be found in our next edition of OPTP magazine. Given the low response, further discussion included looking at the possibility of sharing a list of programs who may still have openings to prospective residents/fellows who do not get accepted. This will be a discussion topic for 2019.

ORFSIG Swag – come check it out at the Academy booth at CSM. PROGRAM DIRECTOR PAYMENT AND SALARY STRUCTURES A work group has been developed to understand current Pro- ABPTRFE RESIDENCY & FELLOWSHIP LEADERSHIP gram Director salaries/benefits to assist program directors in dis- GROUP cussions with administration regarding time allotment for ongoing Communication and collaboration have been a center focus management, mentorship, accreditation, etc. More to come on this in the continued development in residency and fellowship educa- in 2019! tion. We are happy to be working with Kendra Harrington of the ABPTRFE along side the other Residency and Fellowship Lead- ABPTRFE COMMUNICATION AND QUALITY ers from the other Academies/Sections. In 2019 we look forward STANDARDS to building on the communication between ABPTRFE and pro- As many of you already know, the implementation of the new grams. Here we have a community focused on collaboration in Quality Standards will come into effect January 2020. Recently, the overcoming common barriers and building the future of residency new Process and Procedures Manual and Crosswalk document as and fellowship education. well as expectations for Annual Continuous Improvement Report- ing (formally Annual Report) exhibits 2-4 were released. Several COMBINED SECTIONS PRECONFERENCE questions and concerns remain regarding the tracking and sub- EDUCATIONAL COURSE mission of the 57 Primary Health Conditions. The ORFSIG will Kirk Bentzen, Kathleen Geist, Aimee Klein, Tara Jo Manal, continue to work with ABPTRFE in communicating any develop-

ORTHOPAEDIC RESIDENCY/FELLOWSHIP ORTHOPAEDIC and Eric Robertson had their preconference course “Clinical Excel- ments and timelines for implementation. We encourage all pro- lence and Quality Standards in Residency/Fellowship Education” grams to still contact ABPTRFE in addition to the ORFSIG with accepted and presented on Wednesday, January 23rd at CSM. any specific questions or concerns as ellw as sign up for updates on Thank you for helping our programs understand and implement the APTA HUB. the new quality standards. If you would be interested in presenting at CSM 2020, please OPTP QUARTERLY SUBMISSIONS contact our VP, Kathleen Geist at [email protected] The ORFSIG will continue to accept case reports, resident/fellowship research, etc. to be highlighted in future issues of OPTP. ABPTRFE AGGREGATE DATA OF RESIDENCY AND Take this opportunity to highlight your programs participants FELLOWSHIP PROGRAMS AND APPLICANTS REVIEW work! The aggregate data regarding residency and fellowship programs and applicants was recently released. Within this release it Thank you to all our members for their hard work. was identified that there was a surplus in residency and fellowship Matt Haberl, positions. To better understand this data, the ORFSIG established President, ORFSIG

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6938_OP_Jan.indd 56 12/17/18 12:55 PM President’s Message understanding that stems from a source of inspiration extending beyond the tangible. Kirk Peck, PT, PhD, CSCS, CCRT, CERP Successful leaders have vision, or at least an ability to surround Combined Sections Meeting, 2019 - Washington DC themselves with those who are capable of exceptional forecasting. It is my personal hope that in passing the torch of leadership to Another great year has been planned for the APTA Combined the next generation of elected ARSIG officers that a macroscopic Sections Meeting in Washington, DC, January 23-26, 2019. The vision for the future of the organization will continue on an evo- ARSIG Business Meeting will be held from 7:00 a.m.-7:50 a.m. on lutionary path that will ultimately integrate the competencies of Friday, January 25th followed immediately by the two-hour pro- animal physical therapy as an accepted component of practice gramming session starting at 8:00 a.m. The ARSIG Educational within the profession on a national scale. Such a grand vision Session for CSM is entitled, “Manual Therapy For Equine And can be fully accomplished however only if the following condi- Canine Clients: Different Species, Same Concepts,” Presenters: Kirk tions prevail: (1) Statutory laws and regulations in all 50 states Peck PT, PhD, CSCS, CCRT, CERP; Sharon Classen PT, ATC, must legally recognize physical therapy practice on animals; and CERP; and Karen Atlas PT, MPT, CCRT. I sincerely hope to see (2) Accredited programs in higher education must be developed you present in the wonderful District of Columbia come January.

to support the practice of physical therapy on animals based on ANIMAL REHABILITATION

ARSIG Membership formally recognized standards, similar to the current competencies adopted by the Commission on Accreditation in Physical Therapy As of November 10, 2018, the ARSIG website indicated a Education. Elaborating on the second condition, a vision for creat- membership total of 444 licensed therapists. The SIG has continuing a formalized educational program for animal physical therapy ally grown in numbers over the past several years. This is an excel- was actually articulated 40 years ago. lent sign for long-term sustainability, but my fingers remain crossed In the preface of her text published in 1978 on physical ther- that someday a magic number of 1,000 members will appear on apy for animals Ms. Downer stated, “Theconcept of total physical the big screen upon hitting “search” in the web-directory. therapy for animals is not new, but the practice of it by a qualified Six Years Equates to 2190 Days! physical therapist under a veterinarian is new. Still to come are college programs designed especially for training student to become animal Some might claim it was the best thing I ever did. Others might physical therapists.” 1(pV) So I challenge you, and all future great lead- disagree. Either way, now that my term in office is over as ARSIG ers who join the field of animal physical therapy…I ask that you President, I can honestly say I would, without question, do it all not only believe in but also fully embrace a dream that a day will over again if granted the chance. It has truly been an honor serv- come when physical therapists are publically recognized as expert ing as an officer in an organization that I hold great passion for health care practitioners in treating not only humans, but animal on many levels. I firmly believe that the future of physical therapy companions as well. The time has come to see Ms. Downer’s vision involvement with animal rehabilitation and fitness performance come to light. looks bright, especially upon witnessing the next generation of

graduates expressing strong interest in expanding career practice REFERENCES options to include non-human clients. 1. Downer A. Physical Therapy for Animals. Selected Techniques. It has now been 40 years since Ann Downer, BA, MA, LPT, Can Vet J. 1978;19(11):303. published the 1st textbook (1978) in the United States on physical 2. Vision. Merriam-Webster website https://www.merriam-web- therapy for animals. The book was entitled, “Physical Therapy for ster.com/dictionary/vision. Accessed November 9, 2018. Animals: Selected Techniques,” and of interest, the first comment in a book review of Downer’s work stated, “The need for a text which provides an introduction to the principles and techniques of physical Contributory Acknowledgment therapy in veterinary medicine is significant.” 1(preface) It is amazing In this edition of OPTP, Jenny Jones, PT, MS, DPT, CCRT, how true that statement was in the late 1970s, and yet remains just submitted an educational case study on the topic of osteoarthritis as relevant today. Although several excellent text references have in a 10-year-old Cattle Dog. It depicts the challenges and rewards been published by various physical therapists over the past 10 to of implementing a thorough plan of care in rehabbing a dog well 15 years, an incredible void remains in the voluminous amount of deserving of expanding quality in life through improved physical knowledge yet to be shared in the practice of animal rehabilitation. ability. I congratulate Jenny on her contribution of sharing a snip- pet of wisdom and passion for treating the canine species. A Future Worth Dreaming - A Vision Worth Seeking According to Merriam-Webster, the word “vision” may be defined various ways, but the one I believe applies most to evolving professional organizations is, “The act or power of imagination; Unusual discernment or foresight.”2 In essence, vision is not just words crafted on paper to please a board of directors, shareholders, or employees, but rather it is clarity in expression of thought and

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6938_OP_Jan.indd 57 12/17/18 12:55 PM “I was informed by authorities that my mother Subjective pain scores: 3/10 overall, 4/10 during activity, 6/10 was a large Black Bear, but apparently my DNA after activity. Scores are based on client’s observations of increase in test indicated otherwise. I’m just a little Chorkie.” lameness with and especially after activity. Client goals: For Rangler to be pain free, happy, and active.

Physical Examination (7/3/17): Body Condition Score = 5/9 Weight = 50.0 lbs Orientation: BAR, friendly and affectionate, but history of mouthiness with past exams. Other physical findings: Harness donned. Posture: Showing internal rotation in right pelvic limb (RPL). Stands with RPL in mildly odd positions. Tail posture WNL. Able to sit squarely; when standing, shows only partial to non-weight bearing stance in left thoracic limb (LTL). Prefers to lie sternal with L carpus flexed. Transitions: Independent with fair to good use of LTL. Scout & Luna – Truly the Best of Friends! Gait analysis: Stilted PL gait R>L, grade 2 LTL lameness with head bob. Photo Courtesy of Kirk Peck Musculoskeletal exam: Limb girth: TL L 32 cm, R 36 cm. Proximal thigh 43 cm bilat- Contact: erally. Proximal calf L 21.5 cm, R 21 cm. Kirk Peck, President ARSIG Palpation: Peripheral joints all WNL and non-effusive except Office (402) 280-5633 left elbow severely thickened and mild-moderately painful. Right Email: [email protected] hip guarded at end range extension, improved with massage. Psoas comfortable bilaterally. TL ROM: WNL except left elbow 90 degrees flexion with early Physical Rehabilitation in Severe hard end feel, 160 degrees extension with early hard end feel. Osteoarthritis: A Case Study PL ROM: WNL Jenny Moe, PT, MS, DPT, CCRT Spinal mobility: Moderately hypomobile with dorso-ventral SAGE Veterinary Specialty Centers (D/V) pressures in thoracolumbar spine, but no pain. Tail jack Redwood City, CA negative, cervical spine WNL. Neurological exam: Reflexes: LPL- 3+ patellar, 2+ sciatic/cranial tibialis. RPL- 1+ Osteoarthritis (OA) can be a challenging condition to manage patellar, sciatic, cranial tibialis. in the canine population. Conservative management of OA in CP placing: TLs WNL, PLs intact and brisk, but placing wide veterinary medicine is often centered on pain management with bilaterally nutraceuticals, nonsteroidal anti-inflammatory agents, and pain Withdrawals: Present x 4 medications. It is now becoming more commonplace to take a Hopping: Mildly delayed in PLs multimodal approach, with the addition of physical rehabilitation Pain sensation: Present, not formally tested along with acupuncture and laser therapy. Physical therapists can Bowel/bladder function: Normal help patients regulate pain, improve muscle mass for joint protection, and maximize functional ability.

ANIMAL REHABILITATION ANIMAL Assessment (7/3/17): HISTORY Rangler ("Rango") is an approximately 10-year-old NM Aus- tralian Cattle Dog who has a referring diagnosis of elbow arthro- Rangler is an approximately 10-year-old neutered male Austra- sis and hip pain. Rangler presents to physical rehabilitation with lian Cattle Dog who was adopted in May 2017. Rangler was found moderate atrophy of the left thoracic limb with moderate-severe as a stray in a field, so his past medical history is unknown. Rangler left elbow restrictions, mild right distal hind limb atrophy, mild was found to have severe OA in the left elbow as well as OA in the neurological deficits in the pelvic limbs, hypomobility in the tho- coxofemoral joints. Rangler was intact when found, then neutered racolumbar spine, and right hip pain. Rangler will benefit from when a nerve sheath tumor was surgically excised from the right physical rehabilitation to work toward improved strength and hind limb. Rangler underwent electrochemotherapy at the onset of comfort of the left thoracic limb, improved spinal mobility and physical rehabilitation. The recommendations from the orthopedic pelvic limb function, and overall improved exercise tolerance. surgeon included physical rehabilitation. Rangler began with acupuncture in June 2017 while waiting to begin physical rehabilita- Goals (8 weeks): tion in early July 2017. 1. Will demonstrate a 1/4 or better lameness score in LTL. Medications at time of evaluation (7/3/17): salmon oil, gaba- 2. Will tolerate a day of daycare without an increase in LTL pentin 300 mg TID, Dasuquin SID, tramadol PRN, Galliprant lameness. 30 mg SID. 3. Will have an increase in left thoracic limb muscle mass by 2 Environmental concerns: Rangler lives in a two-story home cm to demonstrate improved strength. with tile floors, which causes issues with slipping. There are two other dogs in the home and Rangler also goes to doggy daycare. He is able to jump on/off furniture.

58 Orthopaedic Practice volume 31 / number 1 / 2019

6938_OP_Jan.indd 58 12/17/18 12:55 PM Plan (7/3/17): verse plane releases at pelvic floor, respiratory diaphragm, and tho- Rangler will participate in physical rehabilitation once per racic inlet. Compression through left elbow into shoulder followed week for 4 to 6 weeks, then potentially ongoing at some frequency by leg pull. Occasional rotational mobilizations to thoracolumbar to improve strength and mobility. Rangler's sessions will include spine, grade 3. manual therapy (myofascial release, joint mobilizations, stretching, soft tissue massage), modalities as needed, therapeutic exer- Modalities: cise, balance and proprioception training, and gait training in the LASER - Respond Systems Luminex Vet, class 3b. underwater treadmill. A home program will begin to help Rangler • 808nm 1000mW (1W) continuous wave probe improve strength and ensure smooth progress towards his goals. At • 10 Joules/cm2 to left elbow and bilateral coxofemoral joints home pulsed electromagnetic field therapy would be of significant • 4 Joules/cm2 to each segment of thoracolumbar spine per benefit to Rangler, either with an Assisi Loop or the Respond Sys- side, caudal to scapulae to sacrum tems Bio Pulse bed. A home program was prescribed following review, including Clinical Progress: text and photos for triceps and biceps stretches, tail traction, high - Minimal to no LTL lameness by the end of August 2017, ap- stepping, walking backwards, push-ups, and crawling under. proximately 8 weeks into rehabilitation. PSGAG injections were started (using generic ICHON) with - Able to complete a day of daycare without increase in lame- rehabilitation sessions, following the loading dose weekly and ness by end of August 2017. maintenance monthly injections. - Improved left elbow range of motion comfortable without crepitus, 80° flexion with early hard end feel and 165° exten- Treatment: sion with early hard end feel. Girth measurements showed Therapeutic exercise: mild improvement (2 cm) in RTL. Rangler has been attending physical rehabilitation sessions - Current medications (5/29/18): ICHON injections month- ANIMAL REHABILITATION weekly since his evaluation in July 2017. His sessions initially did ly, Dasuquin, Galliprant, salmon oil, amantadine. not include the underwater treadmill, as he was significantly fearful of the treadmill. We were able to quickly condition him to using Clinical update 5/29/18: the land treadmill and incorporated many dynamic balance exer- Rangler continues with physical rehabilitation weekly to build cises using both the land treadmill, physiorolls, and other equip- and maintain strength in his limbs, as well as work on core strength ment such as Cavaletti rails, memory foam mats, and balance discs to protect his spine. Rangler’s mild proprioceptive deficits and (Figure 1 and 2). Rangler’s sessions also include manual therapy mild hyperesthesia suggest that he may have some mild compres- to improve mobility and flexibility of the spine and extremities. sive disease process in his spine, but an MRI is not indicated at The underwater treadmill was successfully added in February 2018 this time given his high level of function and comfort. He discon- to reduce stress through the extremities and provide resistance for tinued acupuncture at the end of July 2017 to focus on physical strengthening. Water wings are added to provide additional resis- rehabilitation. Rangler is able to walk from his home all the way to tance to the LTL. the clinic and back, 1 mile each way, in addition to going to daycare and playing with housemates, all without lameness. Rangler Manual therapy: thoroughly enjoys his rehabilitation sessions and has made huge Myofascial release, including lumbosacral decompression with strides in not only his physical strength and coordination, but his tail pulls, cross-hand releases to thoracic and lumbar spine. Trans- confidence and fear behaviors as well. He has a wonderful quality of life, and is maintaining his owner’s goals of being happy, painfree and active.

Figure 2. Cavaletti Rails. Rangler navigating Cavaletti rails for range of motion and strength.

Figure 1. Bosu ball. Rangler developing balance and proprio- (Note: Since writing this article, Jenny has opened her own canine ception on a Bosu ball. rehabilitation center, Pawesome PT, in Stateline, NV).

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6938_OP_Jan.indd 60 12/17/18 12:55 PM RESOURCES FROM AOPT TO HELP YOU PREPARE FOR THE ORTHOPEDIC SPECIALTY EXAM Current Concept and Clinical Practice Guidelines (CPGs)

CURRENT CONCEPTS OF ORTHOPAEDIC PHYSICAL THERAPY, 4TH ED. ISC 26.2 Topics and Authors • Clinical Reasoning and Evidence-based Practice— Nicole Christensen, PT, PhD, MAppSc; Benjamin Boyd, PT, DPTSc, OCS; Jason Tonley, PT, DPT, OCS • The Shoulder: Physical Therapy Patient Management Using Current Evidence—Todd S. Ellenbecker, DPT, MS, SCS, OCS, CSCS; Robert C. Manske, DPT, MEd, SCS, ATC, CSCS; Marty Kelley, PT, DPT, OCS • The Elbow: Physical Therapy Patient Management Using Current Evidence—Chris A. Sebelski, PT, DPT, PhD, OCS, CSCS • The Wrist and Hand: Physical Therapy Patient Management Using Current Evidence— Mia Erickson, PT, EdD, CHT, ATC; Carol Waggy, PT, PhD, CHT; Elaine F. Barch, PT, DPT, CHT • The Temporomandibular Joint: Physical Therapy Patient Management Using Current Evidence—Sally Ho, PT, DPT, MS, OCS • The Cervical Spine: Physical Therapy Patient Management Using Current Evidence—Michael B. Miller, PT, DPT, OCS, FAAOMPT, CCI • The Thoracic Spine: Physical Therapy Patient Management Using Current Evidence— Scott Burns, PT, DPT, OCS, FAAOMPT; William Egan, PT, DPT, OCS, FAAOMPT • The Lumbar Spine: Physical Therapy Patient Management Using Current Evidence—Paul F. Beattie, PT, PhD, OCS, FAPTA • The Pelvis and Sacroiliac Joint: Physical Therapy Patient Management Using Current Evidence—Richard Jackson, PT, OCS; Kris Porter, PT, DPT, OCS • The Hip: Physical Therapy Patient Management Using Current Evidence— Michael McGalliard, PT, ScD, COMT; Phillip S. Sizer Jr, PT, PhD, OCS, FAAOMPT • The Knee: Physical Therapy Patient Management Using Current Evidence—Tara Jo Manal, PT, DPT, OCS, SCS; Anna Shovestul Grieder, PT, DPT, OCS; Bryan Kist, PT, DPT, OCS • The Foot and Ankle: Physical Therapy Patient Management Using Current Evidence—Jeff Houck, PT, PhD; Christopher Neville, PT, PhD; Ruth Chimenti, PT, PhD

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